Gum disease: gingivitis and periodontitis

Pink foam in the sink after brushing looks like nothing much, and people live with it for years. It is, however, the only early signal gums are able to send. Healthy gums do not bleed — not from a brush, not from floss, not from biting an apple. If blood appears, there is inflammation at the edge of the tooth. While only the soft tissue is involved, everything is reversible within two or three weeks of proper care. After that the inflammation moves deeper, down to the bone that holds the tooth in the jaw, and that loss does not come back.

What happens where tooth meets gum

A few hours after brushing, a soft film of bacteria builds up on the enamel again: plaque. The bacteria themselves are harmless, the ordinary residents of the mouth; the trouble is the location. Where the gum rests against the tooth there is a narrow groove a couple of millimetres deep that bristles barely reach. Plaque left inside it becomes denser within a day or two, its make-up shifts towards more aggressive microbes, and the tissue answers with inflammation: vessels widen, the gum swells, capillaries tear at the lightest touch.

Another couple of days and the plaque that was never removed takes up minerals from saliva and hardens into calculus, or tartar. No amount of brushing shifts it, and its rough surface holds new plaque better than smooth enamel does. The circle closes.

As long as the inflammation stays in the soft tissue this is gingivitis: the gum is red and bleeds, but the ligament and the bone are untouched, and a thorough clean returns everything to normal. Once it reaches the ligament holding the root and the bony partition between the teeth, periodontitis begins. The gum detaches, the groove turns into a pocket four, six or eight millimetres deep, and the bone at the margin resorbs. The tooth is held by an ever smaller stretch of root — at first this shows only on the radiograph, then it starts to wobble, and in the end it falls out while being perfectly sound, without a single cavity.

What it looks like and what you notice

Periodontitis barely hurts, and that is its cleverest trick. You have to go by other things:

• bleeding when you brush, the earliest sign and the one most often ignored; blood on the floss counts just the same;
• swollen gums, bright red or bluish, instead of a firm pale pink collar;
• persistent bad breath and a bad taste that neither toothpaste nor chewing gum clears, because the source is the pockets rather than the tongue;
• the gum receding, teeth looking longer, the neck of the tooth turning sensitive to cold;
• gaps opening between the teeth where food packs in: that is the bony partition gone;
• teeth starting to shift or splay apart, a change in the bite or in the fit of a denture;
• pus at the gum margin when you press on it.

When a child's or a teenager's gums bleed, the reason is not "the teeth are changing" but the same plaque at the margin, or, less often, an aggressive form in which bone is lost fast and early. Either way it needs looking at.

What drives the inflammation

There is a single cause — plaque — yet the speed of destruction differs several-fold between people, and it depends on things that are largely within reach.

Smoking is the strongest factor after plaque itself. Nicotine narrows the vessels in the gum and the bleeding stops: the person assumes all is well while the bone melts away. Smokers lose teeth earlier and respond less well to treatment.

Diabetes. The link runs both ways: with high blood sugar the gum inflames more and heals more slowly, and treated periodontitis helps blood sugar hold steadier. If periodontitis advances quickly in someone with no obvious reason, it is worth checking glucose — sometimes it is the dentist who first points towards diabetes.

Pregnancy. Hormones change how the gum answers the very same plaque: it swells and bleeds more, and a soft nodule sometimes grows at the margin. It settles after the birth, but the inflammation is better managed than waited out.

A dry mouth. Saliva washes plaque away and neutralises acid. It falls off with many medicines — diuretics, antidepressants, blood pressure and allergy drugs — as well as in some autoimmune conditions and after radiotherapy to the head and neck.

Crowded teeth, overhanging fillings, poorly fitting crowns and braces create corners a brush cannot work in. Stress and short sleep weaken the response to infection and knock the brushing routine off course as well.

There is also a group of causes people rarely think of. Gums that bleed on their own, heavily and not particularly where the plaque is, can be the first visible sign of a blood disorder: acute leukaemia, or a sudden fall in platelets. Gum tissue overgrowing rapidly until it covers the teeth is a recognised side effect of some epilepsy drugs, certain blood pressure medicines and the drugs that suppress immunity after a transplant. Severe, stubborn inflammation in a young person is a reason to remember HIV. And deep vitamin C deficiency, the sailors' disease everyone assumes died out, still turns up in people on an extremely monotonous diet and produces spongy, bleeding gums.

When it cannot wait

See a dentist the same day or the next if:

• the gum has become suddenly painful, is covered with a greyish film and ulcers between the teeth, and there is a putrid smell and a temperature — this is ulcerative necrotising inflammation, and it destroys tissue within days;
• a painful lump with pus has appeared, that is, an abscess;
• a tooth has suddenly become loose or has moved;
• bleeding from the gum will not stop on its own, comes from several places at once, or goes together with bruising on the body and nosebleeds;
• there is an ulcer, a red or white patch, or a firm lump in the mouth that has not cleared in three weeks and does not hurt. Here the absence of pain is not reassuring but the opposite: this is how cancer of the oral lining begins, and caught early it is treated with far lighter means than one left to grow.

Emergency help — the single European number 112 — belongs to a different situation: when swelling from a dental focus spreads across the face, under the jaw or down the neck, and swallowing, opening the mouth or breathing becomes difficult. That is no longer the gum but a spreading soft tissue infection, and the margin is measured in hours.

What the dentist does

First, measuring. A fine graduated probe is walked round the groove of every tooth and the depths are recorded; a radiograph shows the bone level. Those numbers are what separate gingivitis from periodontitis, and they also give the baseline the result is later compared against.

The core of treatment is mechanical removal of deposits: above the gum and, more importantly, below it, inside the pockets, with ultrasonic and hand instruments. It is done under local anaesthetic, usually over two or three appointments. No mouthwash, paste or tablet replaces that work — calculus comes off only with an instrument.

A few weeks later everything is reassessed. Some pockets close, the gum firms up, the bleeding stops. Where a pocket is still deep, the options discussed are flap surgery, which allows the root to be cleaned under direct vision and sometimes grafting material to be added to rebuild bone, or removal of a tooth that has nothing left holding it.

Antibiotics by mouth do nothing for ordinary periodontitis: they do not get into the biofilm clinging to the root. They are kept for abscesses, for the ulcerative necrotising form and for aggressive disease in young people, always alongside cleaning and never instead of it. Stopping smoking is worth doing before surgery rather than after: healing in a smoker is poorer.

The daily routine that actually works

All of the treatment rests on what a person does at home. The practical minimum is short.

• Brush twice a day with fluoride toothpaste, never skipping the one before bed. A soft brush, bristles angled towards the gum, small movements on the spot: pressure is not the point, and hard bristles wear the neck of the tooth and push the gum back.
• Spit, do not rinse. Water washes away the fluoride that should stay on the enamel. For the same reason mouthwash belongs at another time of day, not straight after brushing.
• Clean between the teeth every day. A brush reaches three surfaces out of five, and the disease starts precisely in the gaps. Interdental brushes of the right size do more than floss wherever there are spaces; floss works where the teeth sit tightly together.
• Change the brush as soon as the bristles splay, and always after a serious infection.
• Do not smoke, and do not switch to heated tobacco: for the gums it is no way out.
• Come for check-ups as often as your dentist advises. Healthy gums need only occasional visits; treated periodontitis needs maintenance cleaning regularly and for life, and that is what holds the result in place.

In the first days of proper brushing there is often more blood, not less: that is how inflamed tissue behaves, and it is not an injury from the brush. Within about ten days the bleeding settles. If after three weeks it is unchanged, either the brush is not reaching where it should, or there is already calculus there.

Online consultation

An online appointment does not replace the instrument or the radiograph, but it saves time on the way to them. From your account and a few photographs the doctor can work out what is going on: ordinary gingivitis, an acute flare, or a situation that needs a dentist today. They can help separate bleeding caused by plaque from bleeding that hides a blood disorder or a drug side effect, say which tests are worth having done in advance, and explain how to pick the right size of interdental brush or what to do about a dry mouth caused by long-term medication. Pregnancy and diabetes deserve a conversation of their own: with either, gum care is planned differently.

This material is for information only and does not replace medical advice.