Gum disease

Gum disease is the commonest cause of tooth loss in adults, and it does it to teeth that have nothing wrong with them. Most people have some degree of it, most of them do not know, and the early stage is completely reversible — which is the whole reason it is worth writing about.

It comes in two stages, and the difference between them is not a matter of degree.

Gingivitis: reversible

Plaque left along the gum margin provokes inflammation in the gum next to it. The gum becomes red, slightly swollen and bleeds easily — typically when brushing or cleaning between the teeth, sometimes when biting something firm. It rarely hurts, which is why it goes unnoticed, and most people assume bleeding gums are normal. They are not; healthy gums do not bleed when cleaned.

At this stage nothing has been permanently lost. Remove the plaque thoroughly every day and the inflammation resolves, usually within one to two weeks, and the gum returns to how it was. That is the entire treatment: plaque removal, done properly, by the person whose mouth it is.

Bleeding when daily interdental cleaning is first started is expected and is not a reason to stop — it is the inflammation already present being disturbed. Bleeding that is still happening after a couple of weeks of thorough daily cleaning is a reason to be seen.

Periodontitis: not reversible, but stoppable

In some people, and for reasons that are only partly understood, the inflammation extends deeper and begins to destroy the tissues that hold the tooth in place — the periodontal ligament and the bone of the socket. The damage is done by the body's inflammatory response to the bacteria rather than by the bacteria consuming the bone directly, which is why the same amount of plaque produces very different outcomes in different people.

As the attachment is lost, the gum separates from the tooth and a pocket forms. Pockets are deeper than a brush can reach, they collect more plaque, and the cycle continues inward and downward. Eventually enough support is lost that teeth drift, feel different when biting, and become loose.

The bone that has gone does not grow back. But — and this contradicts a great deal of older writing on the subject — loose teeth are not automatically for extraction. Periodontitis can be stabilised at whatever stage it is caught, and teeth with substantial bone loss can last many years once the disease is halted. Treatment aims at stopping progression, not at reversing what has happened, and that is a worthwhile aim.

Signs worth acting on: gums that bleed spontaneously, bad breath that does not shift, gums shrinking back so teeth look longer, a tooth that has become loose or has changed position, a bad taste, a gap opening between two teeth that used to touch, or discomfort on biting.

What raises the risk

Plaque is the cause. These are the things that decide how much damage it does:

• Smoking, which is the dominant modifiable risk factor. It constricts the blood supply to the gums, which means the bleeding that would otherwise warn of disease is suppressed — so gum disease in a smoker progresses quietly and is often advanced when found. Smokers also lose more bone and respond less well to treatment.
• Diabetes. The relationship runs both ways: poor glucose control makes gum disease worse, and severe gum disease makes glucose harder to control. Treating the gums produces a modest real improvement in control, and a diagnosis of diabetes is a reason to have the gums assessed.
• Genetic susceptibility. Some people are simply more prone, and it runs in families. Someone whose parents lost teeth early has a reason to be assessed rather than reassured.
• Stress, which affects the immune response, and in its extreme form is associated with a particular acute presentation described below.
• Hormonal change. Gums become more reactive in pregnancy and during puberty, bleeding more readily for the same amount of plaque. Pregnancy gingivitis usually settles afterwards, but it needs attention during — and NHS dental care is free in pregnancy and for a year after.
• Some medicines, including particular blood pressure drugs, immunosuppressants and anti-epileptics, which can cause the gum to overgrow and trap plaque. Others reduce saliva.
• Conditions that affect the immune response, and some blood disorders, which can cause gum changes severe enough to be the first sign of them.
• Plaque traps: a filling with an overhanging edge, a badly fitting crown, a partial denture, crowded teeth, fixed braces.

Nutrition rarely causes periodontitis. Severe vitamin C deficiency does cause bleeding, spongy gums, but it is a genuinely rare condition in the UK and not the explanation for the ordinary bleeding gum. A diet that is broadly adequate is adequate; supplements do not treat gum disease.

How it is assessed

By measurement rather than appearance. A fine probe with graduations on it is walked round each tooth, recording where the gum bleeds and how deep the pocket is. Depths of four millimetres or more, bleeding on probing, and gum recession between the teeth are what distinguish periodontitis from gingivitis, and X-rays show how much bone has been lost. The numbers are compared with previous visits, which is how progression is detected while there is still something to protect.

Current practice also grades how fast the disease appears to be moving, which is what decides how aggressively to treat and how often to review. It is reasonable to ask what the measurements were and what they mean.

Treatment

UK guidance works through it in steps, and the order matters.

First, the causes. An explanation of what is happening, personalised instruction in cleaning — which usually means being shown, with interdental brushes sized to the individual's mouth — support with stopping smoking, help with diabetes control where it applies, and removal of plaque traps such as an overhanging filling. Plaque and calculus above the gum line are cleaned off. Then the response is reviewed before going further.

This step is sometimes treated by patients as the preamble to the real treatment. It is the real treatment. Nothing done below the gum line holds if the daily cleaning above it has not changed, and a practitioner who insists on this before proceeding is doing the job properly.

Second, cleaning below the gum line. The pockets are cleaned out mechanically, under local anaesthetic where needed, usually over more than one appointment depending on how much there is to do. Two things are worth knowing in advance, because both surprise people: teeth are often sensitive for a while afterwards, and the gums may appear to recede as the swelling settles and the pockets shrink. The teeth look longer not because the treatment has damaged anything but because the inflammation that was hiding the loss has gone.

Third, whatever has not responded. Further non-surgical treatment, surgery to gain access to pockets that remain deep, or referral to a specialist. Surgical options include reducing the depth of pockets so they can be kept clean, grafting soft tissue over exposed roots, and in selected cases procedures intended to regenerate lost tissue.

Fourth, maintenance, indefinitely. Periodontitis is a chronic condition that is controlled rather than cured, and it recurs if the control stops. Regular review at an interval set by how susceptible the person is, with daily cleaning holding the line in between, is what keeps the result.

Antibiotics are not the treatment for gum disease. They do not remove plaque or calculus, and the disease returns when the course ends; they have a narrow role in particular circumstances only.

Two specific situations

Acute necrotising gingivitis. Rare, but it does not resemble ordinary gum disease and needs urgent treatment. The gums become severely painful, ulcerate and bleed, with grey sloughing tissue between the teeth, a strongly unpleasant taste and breath, and sometimes fever and swollen glands. It is associated with smoking, stress, poor cleaning and anything that lowers immunity. It responds well to prompt treatment and causes permanent damage quickly if left.

Around implants. An implant has no periodontal ligament, and the tissues around it can become inflamed and lose bone in much the same way — peri-implantitis. Implants are not immune to gum disease; if anything they are less forgiving, and they need the same daily cleaning and the same monitoring as teeth.

See also cleaning teeth and gums, dental check-ups, tooth decay and cavities and why dental care matters.