Early-stage periodontal disease (gingivitis) is seldom painful and causes relatively minor signs, such as red, swollen and bleeding gums. But untreated gingivitis can progress to periodontitis, a serious infection that destroys the soft tissue and bone that support your teeth, and eventually may cause tooth loss.
What's more, long-term periodontitis can lead to even more-serious problems, including higher blood sugar levels and an increased risk of heart attack and stroke. Gum disease may even affect your unborn child. Pregnant women with periodontitis are much more likely to give birth to premature babies than are women with healthy gums.
Yet periodontitis is both preventable and treatable. Although factors such as smoking, heredity, medications and lowered immunity make you more susceptible to gum disease, the most common cause is poor oral hygiene. Daily brushing and flossing and regular professional cleanings can greatly reduce your chances of developing periodontitis.
Signs and symptoms
In the earliest stages, periodontal disease causes few signs or symptoms, and you may not be aware of a problem until your gums become soft and bleed slightly when you brush your teeth. As the disease progresses, you may notice more-serious changes, including:
- Swollen, bright red or purple gums
- Gums that feel tender when touched
- Gums that pull away from your teeth (recede), making your teeth look longer than normal
- New spaces developing between your teeth
- Pus between your teeth and gums
- Persistent breath odor or a bad taste in your mouth
- Loose teeth or a change in the way your teeth fit together when you bite
Because several types of periodontitis exist, you may experience problems that are unique to a particular form of the disease. For instance, aggressive periodontitis, which affects otherwise healthy young people, causes an unusually rapid deterioration of their teeth and gums. The condition can also occur episodically, with periods of severe disease alternating with periods when signs and symptoms improve or even seem to disappear.
Other types of periodontitis and their characteristics include:
- Chronic periodontitis. This most common type of gum disease is characterized by progressive loss of the bone and soft tissues that surround and support your teeth. The damage usually develops more slowly than it does in aggressive periodontitis.
- Periodontitis as a manifestation of systemic disease. This usually develops at a young age and occurs in conjunction with another health problem, such as diabetes.
- Necrotizing periodontal disease. A severe form of periodontitis, this causes the death of gum tissue, tooth ligaments and even bone. People suffering from malnutrition or living with HIV/AIDS are especially vulnerable.
Periodontitis begins with plaque. This invisible, sticky film forms on your teeth when starches and sugars in food interact with bacteria normally found in your mouth. Although you remove plaque every time you brush your teeth, it re-forms quickly, usually within 24 hours.
Plaque that stays on your teeth longer than two or three days can harden under your gumline into tartar (calculus), a white substance that makes plaque more difficult to remove and that acts as a reservoir for bacteria. Unfortunately, brushing and flossing can't eliminate tartar — only a professional cleaning can remove it.
The longer plaque and tartar remain on your teeth, the more damage they can do. Initially, they may simply irritate and inflame the gingiva, the part of your gum around the base of your teeth. This is gingivitis, the mildest form of periodontal disease. But ongoing inflammation eventually causes pockets to develop between your gums and teeth that fill with plaque, tartar and bacteria. In time, the pockets become deeper and more bacteria accumulate, eventually advancing under your gum tissue. These deep infections cause a loss of tissue and bone. If too much bone is destroyed, you may lose one or more teeth.
Although the destructive cycle that starts with the accumulation of plaque is the most common cause of periodontal disease, a number of other factors can contribute to or aggravate the condition. These include:
- Tobacco use. Smoking is the most significant risk factor for periodontal disease. Chewing tobacco also contributes to periodontal disease. Tobacco use in any form damages your immune system, putting you at greater risk of periodontal infection. It also creates a favorable environment for harmful bacteria and interferes with the normal mechanisms for limiting bacterial growth in your mouth. Even exposure to secondhand smoke appears to contribute to periodontal disease. And because smoking impairs healing, smokers are less likely to respond to treatment than nonsmokers are.
- Heredity. Sometimes you may do everything right and still develop periodontal disease. In that case, you — along with close to one-third of the population — may have inherited a predisposition to gum problems.
- Drugs. Hundreds of prescription and over-the-counter antidepressants, cold remedies and antihistamines contain ingredients that decrease your body's production of saliva. Because saliva has a cleansing effect on your teeth and helps inhibit bacterial growth, this means that plaque and tartar can build up more easily. Other drugs, especially anti-seizure medications, calcium channel blockers and drugs that suppress your immune system, sometimes cause an overgrowth of gum tissue (gingival hyperplasia), making plaque much tougher to remove.
- Diabetes. A number of health problems can take a toll on your gums. One of the most significant of these is diabetes, which makes you more prone to many infections, including gum infections. But the relationship between diabetes and periodontal disease doesn't end there. Gingivitis and periodontitis impair your body's ability to utilize insulin, making diabetes harder to control. And because diabetes and periodontal disease may make you more susceptible to heart attack and stroke, having both conditions increases your risk of cardiovascular disease.
- Hormonal changes. Changes in hormone levels that occur during pregnancy, menopause or even menstruation can make your gums more susceptible to periodontal disease.
- Nutritional deficiencies. A poor diet, especially one deficient in calcium, vitamin C and B vitamins, can contribute to periodontal disease. Calcium is important because it helps maintain the strength of your bones, including the bones that support your teeth. Vitamin C helps maintain the integrity of connective tissue. It's also a powerful antioxidant that counters the tissue-destroying effects of free radicals — substances produced when oxygen is metabolized by your body.
When to seek medical advice
Healthy gums are firm and pale pink. If your gums are puffy, dusky red and bleed easily, see your dentist. The sooner you seek care, the better your chances of reversing damage and preventing more serious problems.
A healthy tooth has firm, pink gums and strong bone that anchor the tooth firmly to your jaw.
© 1998-2007 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.
Screening and diagnosis
To check the health of your gum tissue, your dentist is likely to use a metal probe to measure the depth of the gingival sulcus, the groove between your gums and your teeth. The probe is inserted beside your tooth beneath your gumline, usually at several sites throughout your mouth.
A depth of 2 or 3 millimeters (mm) — about one-eighth of an inch — indicates healthy gums. A depth beyond 3 mm means a pocket has formed between your gums and your teeth, signaling more serious gum disease.
Having periodontal disease may put you at greater risk of a number of serious medical conditions:
- Heart disease and stroke. Having long-term gum disease may increase your risk of heart attack and stroke. The more severe your gum problems, the greater your risk. Research suggests that the bacteria responsible for periodontitis can travel through your bloodstream to the arteries in your heart where they trigger a cycle of inflammation and arterial narrowing that contributes to heart attacks. Oral bacteria also make you more prone to develop blood clots, increasing the likelihood of a stroke.
- Complications of pregnancy. Women with moderate to severe periodontal disease may be much more likely to give birth to a premature baby than are women with healthy gums. Although the exact association between oral bacteria and low birth weight isn't clear, having gingivitis or periodontitis appears to limit the growth of the fetus in the womb and may trigger high levels of substances that induce labor. This is especially true if gum disease is initially severe to begin with or worsens during pregnancy. The problem is exacerbated in women with diabetes, who are already considered at high risk of pregnancy problems.
- Uncontrolled blood sugar. Diabetes puts you at greater risk of developing periodontal disease and other infections. It also makes blood glucose levels harder to control. That's because infection anywhere in your body can raise your blood sugar level, requiring more insulin to keep it in check.
- Pneumonia. If you have serious gum disease and lung problems, inhaling (aspirating) bacteria from your mouth into your lungs may result in aspiration pneumonia, a condition that's especially common in hospitals where patients may be sedated or have tracheal tubes.
Your gum tissue should fit snugly around each tooth, much as a turtleneck sweater fits around your neck. But when periodontitis destroys supporting bone and tissue, your gum tissue stretches out, allowing bacteria-filled pockets to form around your teeth. Over time, these pockets become progressively deeper and more infected, leading to further tissue and bone loss. The goal of treatment for periodontitis is to thoroughly clean these pockets of bacteria and to prevent more damage.
Many people with periodontitis can be successfully treated with noninvasive therapies. If you have pockets between your gums and your teeth that are 5 mm or less in depth, you may be a good candidate for scaling and root planing, sometimes in conjunction with antibiotic therapy. If you consistently practice good oral hygiene at home, this may be the only treatment you need.
Scaling removes tartar and bacteria from your tooth surfaces and beneath your gums. It may be performed using instruments or an ultrasonic device. Root planing smoothes the root surfaces, discouraging further accumulation of tartar. In addition to these procedures, your periodontist may prescribe antibiotics or other medications to help control bacterial infection. Recent advances in topical antibiotic treatment may reduce the need for systemic medications that, in addition to the potential for side effects, increase the likelihood of antibiotic-resistant bacteria.
Some dentists, for example, recommend antibiotic mouth rinses. Others may insert threads and gels containing antibiotics into the space between your teeth and gums or into pockets after deep cleaning. Although more research is needed, these products appear to lower bacteria levels and may help prevent future problems.
Sometimes, though, you may have more advanced periodontitis — the depth of the pockets between your gums and teeth is more than 5 mm — and your gum tissue may not respond to nonsurgical treatments. In that case, your options may include:
- Flap surgery (pocket reduction surgery). In this procedure, your periodontist makes tiny incisions in your gum so that a section of gum tissue can be lifted back, exposing the roots for more effective scaling and planing. Because periodontitis often causes bone loss, the underlying bone may be recontoured before the gum tissue is sutured back in place. The procedure generally takes from one to three hours and is performed under local anesthesia.
- Soft tissue grafts. When you lose gum tissue to periodontal disease, your gumline recedes, making your teeth appear longer than normal. Replacing the damaged tissue — which is usually accomplished by removing a small amount of tissue from your palate and attaching it to the affected site — serves several purposes: It helps reduce further gum recession; it covers exposed roots, protecting them from decay and making them less sensitive to heat and cold; and it gives your teeth a more cosmetically pleasing appearance.
- Bone grafting. This procedure is performed when disease has destroyed the bone surrounding your tooth root. The graft may be composed of small fragments of your own bone or the bone may be synthetic or donated. Not only does the graft help prevent tooth loss by holding your tooth in place, it serves as a platform for the regrowth of natural bone. In that case, it's usually performed in conjunction with a technique called guided tissue regeneration.
- Guided tissue regeneration. This allows bone destroyed by bacteria to regrow. In one approach, your dentist places a special piece of biocompatible fabric between existing bone and your tooth. The material prevents unwanted tissue from entering the healing area, allowing bone to grow back instead. Another cutting-edge technique involves the application to a diseased tooth root of a gel that contains the same proteins found in tooth enamel. This fools your body into thinking a new tooth is being formed, stimulating the growth of healthy bone and tissue.
The best way to prevent periodontal disease is a program of good dental hygiene, one that you begin early and practice consistently throughout life. That means brushing your teeth at least twice daily — in the morning and before going to bed — and flossing at least once a day. Better yet, brush after every meal or snack or as your dentist recommends. A complete cleaning with a toothbrush and floss should take three to five minutes. Flossing before you brush allows you to clean away the loosened food particles and bacteria.
In addition, follow these tips to keep your gums and your children's gums healthy:
- Choose the right toothbrush. Select a toothbrush with soft, end-rounded or polished bristles — stiff or hard bristles are more likely to injure your gums. The size and shape of the brush should allow you to reach every tooth. Remember that only the tips of the brush do the cleaning, so there's no need to exert extra pressure. Replace your brush every three to four months or even more often. If the bristles are splayed, you've waited too long. Some dentists recommend electric toothbrushes with rotating or vibrating bristles because they may be more effective at removing plaque and maintaining healthy gum tissue than manual brushes are. And electric brushes may be especially helpful for people with arthritis, Parkinson's disease or other problems that affect dexterity. But you don't have to invest a lot of money to achieve good oral health — a manual toothbrush used properly will give good results.
- Brush as if your teeth depended on it. Brushing doesn't do much good if you don't do it correctly. Here's what works: To clean outer surfaces of your teeth and gums, use short, back-and-forth, and then up-and-down strokes. Use vertical strokes to clean inner surfaces. To clean the junction between your teeth and gums, hold your brush at a 45-degree angle to your teeth.
- Floss. If you're like most people, this is the part of oral care you tend to ignore. It's true that flossing is a tedious job, which may be why most dentists say their patients don't floss regularly. Still, flossing is an essential part of effective oral care. Here's how to do it properly: Use about 18 inches of waxed or unwaxed floss. Hold the floss taut and bent around each tooth in a C shape, scraping up and down each side of each tooth. Each stroke should go slightly below your gumline until you feel resistance. Flossing removes plaque between your teeth and helps massage your gums.
- Pay attention to the brushing action, not the type of toothpaste. Some toothpastes claim to remove plaque and tartar or to kill the bacteria that cause plaque. The truth is that all toothpastes, including natural ones without additives of any kind, remove plaque if you brush properly. And no product can remove tartar below your gumline, although anti-tartar or "tartar control" toothpastes can help prevent tartar from building up on your teeth. The bottom line? When used properly, inexpensive fluoride toothpastes remove plaque just as thoroughly as specialty toothpastes.
- See your dentist. In addition to daily oral hygiene, visit your dentist as often as recommended for routine cleanings and checkups.
- Eat a healthy diet. To help protect your teeth and gums, eat a well-balanced diet containing plenty of fresh fruits and vegetables. Consider taking vitamin C and calcium supplements. A potent antioxidant and major player in the synthesis of collagen, vitamin C is essential for healthy gums. Many fruits and vegetables, including citrus fruits, berries, cantaloupe, broccoli and spinach, are rich sources of vitamin C, and most natural foods stores and pharmacies carry vitamin C supplements. Calcium is essential for bone health, and many experts recommend getting 1,200 to 1,500 milligrams of the mineral every day.
Complementary and alternative medicine
Because nutrition plays a major role in oral health, many complementary and alternative therapies focus on supplying your body with certain nutrients. Some of these include:
- Coenzyme Q10 (CoQ10) This substance, which occurs naturally in your body and in a wide variety of foods, plays a key role in the production of cellular energy. It's also a powerful antioxidant — many times more potent than vitamin C. Researchers have studied the potential effect of CoQ10 on a number of conditions, including Parkinson's disease, Alzheimer's disease, cancer, cardiovascular disease and periodontal disease. Among other findings, CoQ10 applied to pockets of diseased gum tissue appears to significantly reduce infection, but no studies have measured the effectiveness of oral CoQ10. If you want to try oral CoQ10, you can purchase supplements at natural foods stores and some pharmacies. Look for oil-based capsules, which are far better absorbed and utilized than dry capsules are.
- Connective tissue nutrient formula (CTNF). This homeopathic formula combines vitamins, minerals and plant extracts believed to enhance the integrity of gum tissue. Clinical trials of CTNF, under the auspices of the National Center for Complementary and Alternative Medicine, a branch of the National Institutes of Health, have shown positive results.
- Grapefruit seed extract. This natural extract has proven antibiotic qualities. Some people suggest adding a drop to your regular toothpaste every time you brush. Look for grapefruit seed extract in natural foods stores or online.
- Cranberries. They're not just for Thanksgiving anymore. Long known as a treatment for urinary tract infections, cranberries and cranberry juice work by preventing bacteria from adhering to cells that line the bladder. Now it appears that cranberries may also keep bacteria from sticking to your teeth and gums. Unfortunately, most cranberry products have sugar added, which can undo the beneficial dental effects. Look for products sweetened with other fruits or fruit juices rather than with sugar. Suggested dose is 3 ounces of juice or six cranberry tablets daily. If you have a tendency to kidney stones or are taking the blood thinner warfarin, talk with your doctor before starting on a cranberry regimen.
- National Institute of Dental and Craniofacial Research
- National Oral Health Information Clearinghouse
- American Dental Association
- American Academy of Periodontology
©1998-2007 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.