Fact sheet: Gingivitis and periodontitis
Gingivitis (inflammation of the gums) often does not cause any immediate symptoms. Yet it may spread to other parts of the periodontium (the bone and soft tissue responsible for keeping our teeth firmly anchored) and cause damage there. This is called periodontitis. Even if this does not cause any symptoms at first, consequences become apparent later on. If periodontitis gets worse, it can lead to teeth becoming loose and eventually falling out. Treatment and better dental hygiene can counteract gingivitis. They can also usually help to slow down periodontitis.
This fact sheet explains what you can do if you have gingivitis to prevent any more health problems. You will also find out about what your treatment options are if gingivitis does turn into periodontitis.
What are the signs of inflamed gum tissue?
Gingivitis is the medical term for an inflammation of the gums (from gingiva, Latin for “gums”). Signs of gingivitis include red or swollen gums and bleeding, mostly while brushing the teeth, or sometimes for no apparent reason. While healthy gum tissue is usually pink in color, inflamed gums tend to be more dark red. The natural color of the gums varies from person to person, however, and gingivitis cannot be diagnosed simply by the color of the gums. Gingivitis frequently causes no pain or other symptoms and remains undetected for quite some time.
One way to detect gingivitis is by having a dental check-up. In Germany, statutory health insurance provides for general dental check-ups twice a year for the teeth and gums to be inspected.
What are the causes of inflamed gums?
The most common cause of inflamed gums is plaque. Plaque is a thin, hardly visible film, made up mostly of bacteria. It is largely found along the gumline, and feels furry to the tongue. The bacteria in the plaque can cause the gums to become inflamed, and this inflammation can cause the gums to swell.
Swollen gums are caused by plaque, but other factors may also favor this condition. For example, it is possible that certain medications that suppress the immune system make these problems worse. These medications are used for treating tumors, for example. Calcium channel blockers like nifedipine can also favor growth of the gums. This drug is used to treat hypertension, for example.
Certain viral infections (with herpes simplex viruses, for example) or other pathogens can also contribute to gingivitis. During pregnancy, mild gingivitis can sometimes become more severe due to hormonal changes if it is not treated. The gums then swell up a lot, can become red and painful, and bleed when the teeth are brushed.
The overwhelming majority of people have had gingivitis either for a short time or regularly. The likelihood of having gingivitis increases with age.
What consequences can gingivitis have?
Gingivitis does not automatically mean that you will have more oral health problems. But sometimes it does get worse and turns into periodontitis – an inflammation of the periodontium. It is unfortunately not possible to predict whether gingivitis will lead to periodontitis for any individual person. But there are indications that vitamin deficiency, immune system disorders and congenital factors could play a part. Smoking and diabetes mellitus also increase the risk of developing periodontitis. If you suspect that you have gingivitis, it is a good idea to pay close attention to your oral hygiene and to talk with your dentist.
What can I do to prevent more severe complications of gingivitis?
Plaque forms very quickly, but it can be removed by thoroughly brushing your teeth several times a day. If plaque is not removed, inflammation of the gums can start within just a few days. Plaque can later harden to form tartar (calculus), further promoting bacterial growth. Plaque can be removed from the teeth by brushing regularly and using dental floss or interdental brushes. You can have tartar removed at the dentist’s office. In Germany, statutory health insurance covers the costs for having tartar removed once a year. It is also possible to have bacterial film removed as part of professional teeth-cleaning. The costs of this procedure are not covered by statutory health insurance, however.
Proper brushing technique ensures that plaque is removed as completely as is possible. It also makes sure that the gums are spared from unnecessary irritation. You can talk to your dentist about which technique and what toothbrushes are best for you individually, and how you can use them.
How does gingivitis turn into periodontitis?
Everyone has a small groove between the tooth and the gums, called the gingival sulcus. If the gums become inflamed, this groove widens and the inflamed gums start to separate from the neck of the tooth. This increases the space between the tooth and gums, allowing bacteria to enter more deeply into the gums. An enlarged gingival sulcus is called a “gum pocket”.
If a gum pocket is several millimeters deep, not only can bacteria collect there, but deposits called concrement can form and harden. They have a darker color than tartar and are difficult to remove. In larger gum pockets parts of the roots of the teeth may be exposed. You can find more detailed information about the structure of the periodontium here.
Bacteria and deposits can cause inflammations in the gum pockets and attack the periodontium. This is considered to be periodontitis if part of the periodontium or the bone is destroyed. If periodontitis advances, with time the teeth may become loose and either fall out or have to be removed.
Periodontitis can progress in episodes. This means that there are short periods where tissue is destroyed that alternate with longer phases where the disease does not progress, or where the tissue can even recover a bit. It is not possible for the gums to grow back, however.
How is periodontitis diagnosed?
Periodontitis often does not cause any symptoms until it has become advanced. But if you know early on that you have periodontitis, it can help you in dealing with this problem. Bleeding gums can be a sign of either gingivitis or periodontitis. Other possible symptoms of periodontitis are gum pockets, teeth that have sensitive necks, decay in the roots of the teeth, or bad breath. If the gums are receding, the gaps between the teeth are widening, or the teeth are becoming loose, periodontitis is already at an advanced stage.
In Germany, statutory health insurance allows members to have a periodontal screening every two years. In this screening the entire mouth is checked tooth by tooth for possible gum pockets using a special periodontal probe. The dentist looks for bleeding gums, possible gum recession, and also sees whether any teeth have already become loose.
Depending on the results of this test, other examinations may be necessary, for example, x-rays, to find out how much of the bone, if any, has been lost. In some cases a test can be done to look for the specific bacteria that cause periodontitis.
What treatment options are there for periodontitis?
Healthy and functional teeth are important for chewing, enunciating and, last but not least, our general appearance. So the goal of treating periodontitis is to stop the progression of the disease as much as possible, in order to prevent further damage and, in the end, any loss of teeth. Even if periodontitis is very advanced and some teeth have already been lost, good care is important for keeping the remaining teeth and being able to place dentures on teeth that have as healthy a periodontium as possible. Besides caring for teeth and gums, there are several different ways for dentists to prevent or treat periodontitis.
Systematic treatment of periodontitis
The systematic treatment of periodontitis is done in several steps:
Improved oral hygiene and professional teeth-cleaning
Subgingival scaling and root planing
Check of treatment success
Possible open surgery
Improved oral hygiene and professional teeth-cleaning
Good oral hygiene is very important for treating periodontitis. To this end your dentist or a specially trained dental hygienist will first dye the plaque on your teeth and then go through the proper use of toothbrush, dental floss and interdental brushes with you.
During a professional teeth-cleaning, deposits that cannot be eliminated by brushing alone (tartar and concrement) are also usually removed by using special instruments and/or ultrasound devices. The teeth can also be polished to remove any remaining plaque, stains or deposits and to smooth the surface of the teeth. During a professional teeth-cleaning the teeth will typically then also be treated with fluoride.
Professional teeth-cleaning has the goal of removing all deposits that are above or at the gumline and that can be removed without using local anesthetic. This should eliminate the causes of inflammation of gum tissue and periodontium. Polishing the surfaces of the teeth aims to reduce the risk of new deposits accumulating.
Subgingival scaling and root planing
If needed, a second phase of treatment is begun. Bacterial deposits and concrement are removed from below the gumline. This procedure is also called “subgingival scaling” or “deep scaling”. This involves cleaning the surfaces of the necks of the teeth and the surfaces of the roots that can be reached using specially shaped instruments to remove concrement and bacteria under local anesthetic. Usually the surfaces are also smoothed, to make it more difficult for bacteria and concrement to build up on them.
Another treatment option is rinsing the gum pockets. An additional benefit of rinsing is contested, however, as there are very few conclusive research results on this procedure.
Check of treatment success
Afterwards, the teeth and gums are examined again to see how successful the treatment was. If these treatment steps have not reduced the depth of the gum pockets enough, or if there is more bleeding, other options may be considered.
In open surgery the dentist applies local anesthetic and makes small cuts in the gums at the points where they are affected by disease, so that they can be flapped back. He or she can then access the surface of the root to thoroughly clean and smooth it. Sometimes the bone is also contoured if it has also been affected by periodontitis. Then the gums are sewn together so that they are once again snug against the teeth.
It usually takes about a week for the wound to heal, and for the stitches to be ready for pulling. The gums can recede after the operation, making the teeth appear to be longer. Some people find this to be unpleasant looking.
In Germany, statutory health insurance funds sometimes pay for this procedure for severe periodontitis if other steps have not brought about sufficient results despite improved dental hygiene.
During open surgery the dentist can also place an additional biodegradable mesh membrane between the tooth and the gums. This aims to stimulate the growth of bone tissue and to prevent quickly growing gum tissue from filling the space surrounding the tooth before the periodontium has had a chance to recover. This procedure is also called guided tissue regeneration (GTR).
In trials, GTR led in part to better regeneration than surgery alone. Yet there has not been enough research on what factors may influence this treatment and who might eventually profit from GTR. In Germany, the costs must be paid for out-of-pocket.
Enamel matrix proteins are another regenerative treatment option. They are applied to the cleaned root surface during surgery. However, there are no trials of a high enough quality to be able to tell whether people with periodontitis will benefit from this treatment. The costs are not covered by statutory insurance funds in Germany.
Bone grafting is sometimes considered when part of the bone surrounding the root of the tooth has been destroyed. This involves grafting small fragments of the patient’s own bone or artificial bone substance in open surgery. These fragments are grafted to give the tooth better support and promote the growth of bone tissue. The additional benefit gained from bone grafting has not been studied sufficiently either.
An important part of treating periodontitis is maintenance to prevent the disease from recurring. At an appointment for maintenance the dentist examines the teeth, gums and periodontium and gives advice about improving dental care. You can only avoid periodontitis from recurring if you also take good care of your teeth at home. The best protection against plaque, tartar, concrement and recurrent periodontitis is optimal dental hygiene using a toothbrush, dental floss and interdental brush, several times a day.
Routine professional teeth-cleaning can support individual oral hygiene. According to research done so far, it is not possible to give a general estimate of how often professional teeth-cleaning is advisable. Depending on individual oral hygiene and how severe the periodontitis was, usually about 1 to 4 sessions a year are recommended. Adverse effects of professional teeth-cleaning may include damage to the teeth or gums, and more sensitive teeth. One positive side effect is that stains on the teeth can be removed.
As part of what is called supportive periodontitis treatment (SPT), in addition to professional cleaning, the dentist can regularly measure how deep the gum pockets are. After looking at the examination results and the existing risk factors the dentist can talk with you about the options for reducing risk – if needed – and find the best time for the next check-up.
In Germany, if certain conditions are met, statutory health insurance funds cover the costs for systematic periodontitis treatment to a limited extent. But you must apply for in advance. You can ask your insurer which of the individual procedures described here is covered.
Reducing the amount of germs in the mouth
Chlorhexidine can be used to reduce the amount of germs in the mouth as much as possible, and supplement mechanical cleaning. Chlorhexidine is an antibacterial agent that is also found in some mouthwash products. This additional treatment aims to prevent germs from settling in the gum pockets directly after a professional teeth-cleaning and immediately attacking the gums again.
Research results indicate that the depth of the gum pockets could be reduced somewhat when the mouth is disinfected after subgingival scaling. Yet it cannot be said exactly how much this treatment can help, so the advantages and disadvantages have to be weighed. Chlorhexidine is a strong disinfectant and can cause stains on the teeth when it is used for a longer period of time.
You can also use mouthwash to reduce the amount of germs as part of your oral hygiene routine independently of professional teeth-cleaning.
Treatments for avoiding strain to teeth
Periodontitis is sometimes thought to be made more likely if neighboring or opposite teeth exert too much pressure on the tooth that is affected by periodontitis. This can be caused by things like nighttime grinding of the teeth (bruxism), misaligned teeth, or a filling that sits too high. There are different treatments that can be applied to reduce this strain. For example, the chewing surface of the affected tooth is contoured, or a splint is used to try and reduce pressure. But there is hardly any research on whether these kinds of treatments contribute to the healing process in people who have periodontitis.
What helps other people to cope with periodontitis?
Some people have a bad conscience because they feel that they do not pay enough attention to their dental hygiene or because they keep on smoking even though they are aware of how harmful it is. They are also sometimes afraid of losing teeth due to periodontitis. People with periodontitis say that it helps to have a dentist who is supportive, understanding and motivating. Being well-informed and regularly talking with their dentist about how the treatment is going also seem to be helpful. This also includes talking with your dentist about what you are doing well and where you could still improve in your dental hygiene routine.
In order to get a handle on periodontitis and keep the periodontium healthy for as long as possible, the most important thing to do is to properly care for your teeth and gums. For that it is essential to start daily routines of dental care – and to stick to them. Regularly brushing your teeth, always keeping the correct brushing technique in mind and not forgetting floss or interdental brushes: all of this requires commitment and poses quite a challenge. Yet many people say that they have an easier time with dental hygiene when they start to notice how it improves the health of their teeth.