The following FAQs provide answers to many common questions about gum disease including the symptoms, the causes, the risk factors involved, the best ways to prevent it, and how it can be treated both by professional dentists and through good oral hygiene at home.
What is gum disease?
Gum disease involves the inflammation of the gums
It is caused by the build-up of bacterial plaque in the mouth, which leads to an inflammation of the gum line, known as gingivitis. If this is not treated, the inflammation can spread to the bones and other structures that support the teeth, which leads to the more serious disease of periodontitis. “Pockets” may form in the gums, where harmful bacteria can accumulate and provoke more inflammation, leading to bone loss. As a result, teeth become loose and may eventually fall out.
In the case of implants, bacterial plaque leads to an inflammation of the gum around the implant (peri-implant mucositis) which, if left untreated, can quickly lead to the more serious condition of peri-implantitis, which involves bone loss and can eventually mean the loss of the implant.
What is gingivitis?
Bacterial plaque on the teeth can provoke the inflammation of the gum line, a condition known as gingivitis. The gums (the gingiva) react to the presence of dental plaque by becoming inflamed – and this can happen after only a few days.
This inflammation – usually involving reddened or swollen gums – is the body’s response to the bacteria that have been allowed to accumulate on the teeth.
Gingivitis is a common inflammation. If optimal oral hygiene at home is practiced and if the bacterial plaque is removed regularly, gums can recover within a few days.
However, if gingivitis is not addressed, the symptoms can worsen and lead to the more serious gum disease of periodontitis.
During pregnancy, there is an increased tendency for gingivitis because of hormonal changes. Pregnant women should pay special attention to good oral hygiene and see a dentist at an early stage during their pregnancy (See: Guidelines for women on oral health and pregnancy).
What is periodontitis?
Periodontitis is a gum disease. It is a chronic inflammatory disease that is triggered by bacterial microorganisms and involves a severe chronic inflammation that causes the destruction of the tooth-supporting apparatus and can lead to tooth loss. It can also lead to other health problems.
Periodontitis always begins with inflammation of the gums, known as gingivitis. This inflammation – usually involving reddened or swollen gums and bleeding when brushing teeth or biting on food – is the body’s response to bacteria that have been allowed to accumulate on the teeth.
This inflammation can then spread to below the gums and along the roots of the teeth. This can cause permanent damage to the tissues (or “periodontal ligament”) around the teeth and to the supporting bone. Teeth start to loosen and can eventually be lost.
This can then lead to problems with chewing food and with speaking, as well as causing aesthetic damage to your smile.
In many people, this is a gradual process that takes place over many years. However, some young adults have a very active form of the disease, which causes early loosening and loss of the teeth. Around 40 percent of people suffer from periodontitis. Among adults, it is estimated that around 70% of tooth loss is caused by periodontitis.
The good news is that – if detected and treated – the process can be halted and gum health can be restored.
The word “periodontitis” comes from “periodontium”, which means “surrounding (peri) the tooth (odont)”. The periodontium includes all the components that hold the tooth in the jawbone: the gum (gingiva), the bone, the anchoring fibres, and the anchoring structure on the surface of the root (cementum). In a healthy tooth, the periodontium surrounds the entire root.
What are the symptoms of periodontitis?
Periodontitis always begins with inflammation of the gums, known as gingivitis. One of the first signs is that your gums bleed when you brush your teeth. The gums may look red and swollen and you might notice a discoloured layer of bacterial plaque on the teeth. If not removed through proper cleaning of the teeth, this plaque will become “mineralised”, turning into hard deposits known as calculus or tartar, which cannot be removed by a toothbrush.
Left untreated, gingivitis may turn into periodontitis, a more serious form of gum disease. Often this happens without any obvious signs to alert you, but you might notice changes such as:
- Increased bleeding from the gums, which may be provoked by tooth-brushing or eating, or may even be spontaneous.
- Bad breath.
- Changes in the positioning of the teeth in the jaws.
- Teeth appear “longer” (receding gums).
In smokers, gum bleeding may be less noticeable. This is because of the effect of nicotine on blood vessels and means that the progress of the disease may be hidden.
People do often not notice the presence of periodontitis until they are 40 or 50 years old, by which time a great deal of damage may have occurred. However, a dentist can detect signs of the disease much earlier, during a routine dental examination, and can monitor your periodontal status by using a tool called the Periodontal Screening Index. You should ask your dentist for a periodontal examination as part of your regular dental check-ups.
What is the difference between gingivitis and periodontitis?
Gingivitis is an inflammation that is limited to the gum line, while in periodontitis there is loss of the jawbone, periodontal ligament, and root cementum.
In gingivitis, there is not yet any loss of the structures that hold teeth in place. This means that good oral hygiene at home can stop the gingivitis and restore healthy gums.
But with periodontitis, it is different. Once the inflammation has caused bone loss, this damage cannot be repaired.
Treating periodontitis requires more than good oral hygiene at home. It needs professional care from a dentist or periodontist.
My gums are receding: does that mean I have periodontitis?
Receding gums are not always caused by periodontitis.
Sometimes, receding gums are provoked by brushing your teeth too vigorously, which injures the gum line. When it heals, the gum line withdraws further until the tooth root beneath the gum is exposed. Even if you change your oral-hygiene habits and clean your teeth less forcefully, gum recession will not be reversed.
In periodontitis, the initial damage to the tooth-supporting structure may not be visible and the gums may recede only after the disease has established itself.
If you have receding gums, your dentist will be able to examine them and explain whether periodontitis is the cause and offer you the appropriate treatment.
What are the causes of periodontitis?
The simple message is that periodontitis is always caused by the build-up of bacteria in the form of dental plaque.
A healthy mouth is colonised by more than 700 different species of bacteria, most of which are completely harmless and live in harmony with their “host”. But when we do not clean our teeth thoroughly enough, bacterial deposits build up next to the gums, forming a “plaque” – and this creates the conditions for more dangerous bacteria to flourish. The natural defences of the body are also compromised as a result.
If this bacterial plaque, which is soft, is not removed by brushing, minerals are deposited within it and a hard deposit on the tooth called tartar (or calculus) is formed. The presence of tartar encourages the growth of the bacterial plaque towards the roots of the teeth. This leads to a weakening of the attachment of the root to the gum and the creation of a gap – called a periodontal pocket – between tooth and gum. This pocket is an ideal place for harmful bacteria to gather and multiply, which drives disease forward as the bacteria release toxins that further trigger the body’s defence mechanisms.
The severity and speed with which periodontitis progresses depends on factors including:
- the number and type of bacteria present.
- the strength of an individual’s defences.
- the presence or absence of risk factors (e.g. smoking, diabetes).
- genetic factors.
- certain types of medication.
For example, the more aggressive the bacteria and the weaker the immune response of the patient, the more active will be the disease. And if the patient is a smoker or has diabetes, the body’s defences may be weakened which can speed up the disease process. Some drugs – such as antihypertensive or vasodilating agents and immunotherapy – can affect the inflammatory response to plaque and make patients more susceptible to gingivitis.
But it is very important to remember that without the accumulation of bacterial plaque, periodontitis will not occur.
What are the consequences of periodontal disease
Tooth loss: If the progress of periodontal inflammation is not halted, the supporting structures of the teeth – including the surrounding bone – are destroyed. The teeth eventually loosen and are either lost or need to be extracted. Among adults, it is estimated that around 70% of tooth loss is caused by periodontitis.
Problems with eating: Periodontitis weakens the structures that hold the teeth in place. Wobbly teeth can cause problems when chewing. People affected can to some extent adapt and switch their chewing habits to the teeth that can still be used. But if the damage continues – and especially if teeth are lost – people can end up able to eat only soft foods.
Problems with speaking: the loose teeth caused by periodontitis can make it difficult to speak clearly. If the visible front teeth in the upper jaw are forced apart because of periodontitis, the gaps that arise can cause problems in speaking (for example, sibilant sounds like “S” may not be pronounced clearly). Singers and musicians who play wind instruments can also have problems if teeth start to move apart as a result of periodontitis.
Problems with appearance: People with periodontitis can have problems with their appearance (aesthetic problems). Gums are dark red because of inflammation, teeth look longer because of receding gums, and the roots (which are darker than the crowns of teeth) become visible – all of which can look unattractive. As teeth loosen, they can move apart leaving dark spaces (black triangles) between them, and if teeth are lost as a result of periodontitis there can be unattractive gaps.
Bad breath: The bacteria that cause the inflammation involved in periodontitis can also cause bad breath (halitosis). The kinds of bacteria that cause periodontitis thrive in gum pockets and produce foul-smelling volatile sulphur compounds. Bad breath needs to be treated by professional teeth cleaning and good oral hygiene at home.
Negative effects on general health: It is now known that untreated periodontal disease can have serious consequences for general health. Periodontitis means an increased risk of suffering diabetes, heart disease, cerebrovascular disease, and complications in pregnancy (pre-eclampsia, premature birth and low birth weight).
In fact, periodontitis has been linked with more than fifty diseases and conditions, including chronic kidney disease, Alzheimer’s Disease, rheumatoid arthritis, and certain types of cancer.
What are the risk factors for periodontitis?
There are several factors that increase your chance of developing periodontitis and make the disease more likely to progress. Among the common risk factors are:
- Smokers are much more likely to develop periodontitis than non-smokers.
- Periodontitis progresses much more quickly – and with more rapid loss of teeth – in smokers than in non-smokers.
- Even with good oral hygiene at home, smokers experience greater bone loss and are more likely to develop gum pockets that house a greater number of harmful bacteria.
- Periodontal treatments (e.g. implants and gum or bone grafts) are less successful in smokers than non-smokers because healing is generally poorer.
- About 90% of cases where periodontitis does not respond to treatment involve smokers.
- In ex-smokers, the condition of the gums can improve within a few years and with good professional care. Just one year after quitting, former smokers respond better to treatment than patients who still smoke.
- Quitting smoking is strongly advised.
- Some people may have more of a genetic predisposition to suffering gum disease than others.
- The way the immune system reacts to harmful bacteria can differ from person to person because of genetic differences. As a result, people do not all develop the same symptoms of periodontitis.
- Periodontitis can start at the age of 18 in rare cases, and in very rare cases even in adolescence.
- But most cases develop after the age of 35.
- Because the disease usually progresses slowly, those affected do not detect the first problems until much later – sometimes when it is already too late.
- In old age, the consequences of periodontitis can be more serious, in terms of greater bone loss and more tooth loss.
- Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis.
- Periodontitis and diabetes have a two-way effect on each other. Diabetics whose blood sugar is not managed have a higher risk of developing periodontitis. And patients with periodontitis have a higher risk of suffering diabetes.
- Diabetics with well-managed blood-sugar levels do not have a higher risk for periodontitis.
- The treatment of one disease has a positive effect on the treatment of the other.
- It is important that people with diabetes are examined by a dentist to see if they have periodontitis and patients with periodontitis should be tested for diabetes by their doctor.
- More information on Perio & Diabetes
- An unhealthy diet – one high in processed foods and refined carbohydrates – increases the tendency for gums to become inflamed.
- In both gingivitis and periodontitis, this can lead to more swelling at the gum line and increased damage to the tooth-supporting structures.
- An unhealthy diet also increases the risk of diabetes, which can further exacerbate periodontitis.
- Mental and emotional stress can weaken the immune system and lower the resistance of the gums to harmful bacteria.
- People with a weakened immune system may be more susceptible to gum disease.
- The resulting greater bacterial load adds to the unfavorable effect on an already compromised immune system.
- Individuals suffering from stress or depression may spend less time on their daily oral hygiene at home.
What can I do to prevent periodontal disease?
Inflammation of the gums is neither normal nor inevitable. Gum diseases –gingivitis and periodontitis – can be prevented by looking after your teeth and gums. This means adopting good habits in oral hygiene and getting regular professional check-ups (at least once a year).
The basic elements of good oral hygiene are:
- Brush your teeth at least twice a day, for at least two minutes, using a manual or an electric toothbrush.
- Clean between teeth at least once a day using interdental brushes (also known as interproximal brushes) and dental floss if the gaps are too small for brushes. You may need to use differently sized brushes for differently sized gaps. This interdental cleaning should be done before brushing your teeth.
- After brushing your teeth, antiseptic mouthwashes may be used as they can prevent plaque accumulation for up to 12 hours. Chlorhexidine mouthwashes are the most efficient, but have some side effects such as tooth staining, black tongue, change in taste, and sometimes erosion of the mouth’s soft tissues. Chlorhexidine mouthwashes are recommended to be used for a maximum of two weeks. Ask your dentist whether you should use a mouthwash, and which one would be appropriate to your situation.
Special care should be taken to clean thoroughly around crooked or crowded teeth, and around fillings, crowns, and dentures because plaque builds up easily in these places which might be hard to access.
Optimal oral hygiene can therefore vary widely from person to person. It is important to consult your dentist or dental hygienist about which are the best techniques in your case and to ask them for instructions.
There are two main tooth-brushing techniques. The Bass tooth-brushing technique is the most commonly recommended technique both for people with healthy gums and with periodontitis. The Stillman technique is often recommended for patients with gingival recessions.
Watch these videos on how to perform tooth cleaning at home:
If your cleaning technique is poor, deposits of plaque remain on the teeth and will become “mineralised”, turning into hard deposits known as calculus or tartar, which cannot be removed by a toothbrush. But your dentist or periodontist (a dentist who specialises in periodontal health) can identify these deposits during a regular check-up and remove them as part of professional cleaning. Once the tartar is removed, the teeth are polished (using special cups and pastes) to create a smooth surface that is less likely to accumulate plaque.
Ask your dentist for a basic periodontal examination as part of your regular dental check-up.
Addressing risk factors can also help prevent the onset of periodontitis. So, giving up smoking, avoiding or reducing stress, eating a healthy diet, and exercising can all play a role in supporting good oral hygiene in preventing periodontitis
How is periodontitis diagnosed?
There are several stages involved in diagnosing periodontitis.
1. Clinical examination
A clinical examination in the dental practice is the only way to properly assess the condition of the gums and the tooth-supporting structures.
In an initial check-up, the dentist or hygienist will perform a basic periodontal examination that takes only a few minutes. This examination quickly determines if gingivitis or periodontitis is present.
The dentist or dental hygienist will use a special probe (called a periodontal probe) and the depth of penetration at the gum line is measured gently and precisely at various sites in the mouth. The probe measures the distance between the gum line and the bottom of the “pocket”. At healthy sites, the probing depth is 3mm or less, but where periodontitis is present, the depth is 4mm or more.
After this short examination, further tests are carried out only if there is evidence of periodontitis – i.e. damage to the tooth-supporting structures.
In addition, in what is termed a periodontal chart, the height of the jawbone (attachment level) is recorded precisely. A periodontal chart is indispensable for the correct diagnosis of periodontitis and for planning subsequent treatment.
The diagnosis of periodontitis can be confirmed only by carrying out X-rays. The selection of the X-rays needed to diagnose periodontitis is made after the clinical examination.
In the simplest cases, only two images (so-called “bite-wing” images) are needed, but more extensive cases may require up to 14 additional X-rays and/or a panoramic X-ray of the whole mouth. These X-ray images show the jawbone surrounding the tooth and make it possible to estimate the severity of bone loss.
In each X-ray made at the dental practice, teeth must be checked for caries as well as for periodontitis.
3. Microbiological tests
Microbiological tests examine the composition of the dental plaque for specific harmful bacteria:
- Prevotella intermedia
- Porphyromonas gingivalis
- Agregatibacter actinomycetemcomitans
- Treponema denticola
The results of these tests can provide information that will enable the dentist or periodontist to provide the appropriate care and avoid unnecessary treatment.
4. Classifying the disease
There is an internationally recognised system for classifying cases of gingivitis and periodontitis.
Cases of periodontitis are classified according to four stages and three grades. The stages describe the severity and extent of the disease, while the grades describe the likely rate of progression.
By classifying cases of periodontitis in this way, dentists and periodontists can provide the appropriate form of treatment for each individual patient.
How is periodontitis treated?
With careful professional assessment and treatment, it is usually possible to completely halt the progress of periodontitis. The key to success is eliminating the bacterial plaque that triggers the disease process and establishing excellent oral-hygiene practices. There are six stages in the successful treatment of periodontitis:
- Oral-hygiene instruction and advice
The aim of the oral-hygiene phase of treatment is to reduce the number of bacteria in the mouth and thereby reduce the level of inflammation. Your dentist will first explain the causes of your periodontitis and give you clear instructions on how to keep your teeth and gums clean. You will be given advice on how to use different tools and techniques: for example, the most appropriate tooth-brushing technique and the correct use of interdental brushes, dental floss, and antiseptic mouthwashes.
- Professional cleaning
All bacterial deposits (plaque and tartar) are removed from accessible areas of the teeth, and the teeth are then polished and treated with fluoride. If necessary, the dentist will also remove all bacterial deposits and tartar from the root surfaces and gum pockets.
- Antibiotic therapy
In some cases, antibiotics are prescribed to deal with active or persistent gum infections that have not responded to oral-hygiene measures.
After several weeks, your dentist or periodontist will make a full assessment of your gums to check the progress of your treatment. A special instrument called a periodontal probe is used to record the depth of any periodontal pockets and check for bleeding from the gums. If periodontal pockets greater than 3mm are still present, further treatment options may be suggested, including corrective surgical therapy.
- Corrective surgical therapy
Sometimes, a surgical procedure is carried out to remove plaque bacteria and deposits within periodontal pockets and on the root surfaces at the furcations (where the roots diverge). These areas are inaccessible to brushes and floss, so inflammation will stay there as long as bacteria are allowed to colonise them. Under local anaesthesia, the gum is raised and the root surfaces are cleaned to ensure that all bacteria are removed. It is sometimes possible to treat bone loss at the same time using a special regenerative treatment. At the end of the procedure, the gums are stitched back into place around the teeth. Stitches are usually removed between one and two weeks after surgery. It has also been shown that regenerative periodontal surgery – which aims to reconstruct lost bone around the teeth – improves the prognosis of the teeth, prolonging their longevity and making them maintainable
- Aftercare – supportive periodontal therapy
The long-term success of periodontal treatment depends on two factors: the patient’s own oral hygiene and regular care from their dentist or periodontist. After the first phase of treatment has been completed, your dentist will need to review the condition of your gums at regular intervals to check that the inflammation has been halted and has not returned. The frequency of your follow-up appointments will depend on the severity of disease and your individual risk of disease progression. Usually, follow-up visits are scheduled for every three to six months.
Regular follow-up appointments are vitally important to ensure that periodontitis does not return and cause further destruction of the gums and the bone and ligament that support the teeth. If there are signs of continuing disease, your dentist will be able to treat it at an early stage. You will also be given advice on how to change your oral-hygiene practices to tackle the inflammation.
Successful periodontal treatment requires your full co-operation in daily oral-hygiene practices and attendance at regular follow-up appointments.
What is periodontology?
Periodontology is the study of the specialised system of hard and soft tissues that support your teeth and keep them in their place in the jaw. This apparatus, known as the periodontium, has some very important functions:
- It securely attaches the teeth to the jaws.
- It acts as a shock absorber during biting and chewing, and so helps to prevent damage to the teeth.
- It maintains the teeth in a stable position within the jaws so that that they work together efficiently and comfortably during chewing.
The periodontium is made up of several individual structures that work together:
- The tooth socket: the bony pouch in the jawbone in which the tooth is positioned.
- The cementum: a layer that covers the roots of the teeth.
- The periodontal ligament: a complex arrangement of tiny fibres, between the root cementum and the tooth socket, which holds the tooth in place almost like a sling.
Because the different parts of the periodontium are made from living tissues, they can adapt to changes in our mouths over time, making the tiny changes in shape and thickness that keep the position of the teeth stable.
In many ways, the mouth acts as a mirror of the general condition of our bodies. Our periodontal status can often tell us more than simply what is happening locally in our gums. Although periodontitis is always triggered by the accumulation of plaque on the teeth, diseases affecting the rest of the body – known as systemic diseases – can weaken the supporting structures of the teeth.
Also, some serious disorders are known to show themselves in the mouth before they are evident in any other part of the body. Sometimes a trained periodontist is the first person to detect the signs of a general disease, such as diabetes or blood disorders, when examining a patient’s mouth.
What is a periodontist?
Periodontists are dental practitioners who specialise in the prevention and treatment of diseases of the tooth-supporting tissues – the periodontium. Although all dentists receive training in the diagnosis and treatment of mild to moderate periodontal disease, severe or complex cases are usually referred to a periodontist, who will have undertaken additional training and acquired special expertise in the area.
Within the field of periodontology, there is also a range of different specialist procedures that focus on specific types of treatment. The treatments a periodontist provides include: non-surgical periodontal therapy, regenerative periodontal therapy, soft-tissue grafting and recession coverage, pre-prosthetic surgery, and bone reconstruction with implant placement or therapy.
Click here for more information on training to be a periodontist.
What are the links between periodontitis and other diseases?
There are well-established links between periodontitis and several other diseases that can have serious consequences for general health.
There is a two-way relationship between periodontitis and type-2 diabetes: people with periodontitis have a higher risk of diabetes and patients with diabetes are three times more likely to develop periodontal disease.
There are higher levels of insulin resistance in people with periodontitis and controlling diabetes is more complicated when a patient also has periodontitis.
People who have both diabetes and periodontitis are at greater risk of suffering some severe medical complications – including cardiovascular disease, chronic kidney disease, and retinopathy – than people who have diabetes alone.
The treatment of one disease has been shown to have a positive effect on the treatment of the other. For instance, periodontal treatment in people with diabetes results in a significant reduction in blood-sugar – glycated haemoglobin (HbA1c) – levels.
It is important that people with diabetes are examined by a dentist to see if they have periodontitis and patients with periodontitis should be tested for diabetes by their doctor.
For more information: EFP Perio & Diabetes campaign:
- Recommendations for patients and the public
- What you should know, what you should do
- Perio and Diabetes: FAQs
- Infographic: People with periodontitis are likely to develop diabetes mellitus – and vice versa LINK
- Infographic: Periodontal treatment for people with diabetes
- Video: Perio and Diabetes
Periodontitis is associated with several forms of cardiovascular diseases (CVD) and may be a preventable risk factor for suffering these diseases.
Gum disease is a chronic condition that may make it harder to prevent CVD and it may even aggravate CVD in patients who already have the disease.
There is evidence that periodontal treatment and correct oral hygiene helps in the prevention of CVD. For instance, patients who brush their teeth twice a day and have a good oral-health routine may have less risk of acute CVD events.
Periodontal treatment in CVD patients is safe, although in some cases – where patients receive anti-coagulant or anti-platelet therapy – safe haemostatic measures need to be taken.
Problems in pregnancy
During pregnancy, increased hormonal levels can affect the way that the body reacts to dental plaque and this can lead to swollen and bleeding gums (gingivitis) and to the more serious form of gum disease known as periodontitis.
Associations between gum disease and adverse pregnancy outcomes have been demonstrated: a pregnant woman with poor gum health runs a greater risk of suffering from pre-eclampsia, of giving birth prematurely, and of giving birth to an underweight child.
Maintaining oral health and gum health during pregnancy is crucial both for pregnant women themselves and for their unborn children.
For more information: EFP Oral Health & Pregnancy campaign
- Guidelines for women on oral health and pregnancy
- Key messages for women on oral health and pregnancy
- Oral health and pregnancy: FAQs
- Infographics on oral health and pregnancy:
- Videos on oral health and pregnancy
Periodontitis has been linked with more than fifty diseases and conditions, including chronic kidney disease, Alzheimer’s Disease, rheumatoid arthritis, and certain types of cancer.
For more information: EFP Manifesto: Perio & General Health