Gum Disease

Gum disease often starts without pain. Any of the following signs is a reason to see a dentist²:

• Gums that bleed when you brush or eat something hard
• Red, swollen or sore gums
• Bad breath that does not go away
• Gums pulling back from the teeth, so that the teeth look longer (recession can also happen without disease)
• In advanced disease, teeth that become loose or move out of place

Does a little bleeding mean disease?

The definition of healthy gums does not require that they never bleed. In a mouth considered healthy, bleeding can occur at fewer than 10 per cent³ of the points the dentist measures. Gingivitis is diagnosed when the bleeding points reach 10 per cent or more⁴. A single bleeding point is not a diagnosis. These percentages refer to points the dentist measures with a probe; they do not apply to bleeding you notice at home. Whether you have periodontitis is decided by also measuring pocket depth and the loss of supporting tissue. Even so, bleeding that keeps recurring when you brush should be checked.

The main cause is bacterial plaque that builds up on the tooth surface and along the gum line. Plaque that is not cleaned away hardens and turns into tartar⁵. The rough surface of tartar makes it easier for new plaque to stick.

• Smoking. In an analysis that pooled 14 prospective studies, the risk of periodontitis starting or getting worse was about 85 per cent higher⁶ in smokers. This is observational evidence. Smoking also weakens the response to treatment; stopping can prevent further deterioration³.
• Diabetes. It is assumed that anyone with diabetes has a higher risk of gum disease. Well-controlled diabetes is not counted as a risk factor on its own, but blood sugar control can change over time.
• Some medicines. Medicines that cause a dry mouth, such as some antidepressants, and medicines that can cause gum enlargement. Gum enlargement is seen most often with calcium channel blockers, a group of blood pressure medicines.
• Pregnancy. Gums swell and bleed more easily in pregnancy; this is covered separately below.

The evidence on how stress, diet, weight and cannabis use affect gum disease is insufficient³.

How common is it?

In the United Kingdom, about half of adults³ have some degree of irreversible periodontitis. Severe periodontitis affects about 10 in every 100 people³ in the world's population and peaks most often at ages 60 to 64. We cannot give a comparable figure for Turkey on this page.

When treatment is needed

• Anyone found to have gingivitis or periodontitis at an examination. How much treatment is needed depends on the stage of the disease.
• People with diabetes who have periodontitis. Gum treatment can also help blood sugar control; the details are in the risks and benefits section.

When treatment may not be needed, or another route is considered

• Receding gums without signs of disease. Recession is common in adults and increases with age. If there are no signs of disease, monitoring the receded area⁷ is considered the appropriate approach; not every recession needs an operation. If the recession is getting worse, if the root is sensitive, decayed or worn, or if the appearance bothers you, surgery may be considered⁷.
• Healthy gums. If your gums are healthy, you do not need a deep cleaning. Your dentist decides how often routine cleaning is done. The research finding on this is in the questions section of the deep cleaning page.
• Gum problems not linked to plaque. Some gum conditions usually do not clear up⁸ when plaque is cleaned away, and they can be a sign of a general illness. These need a separate assessment.

Tell your dentist before treatment

If you take a blood thinner or any other regular medicine, have diabetes or heart disease, or are pregnant, tell your dentist before treatment. Do not stop or change⁹ your blood thinner for dental treatment unless your doctor or dentist tells you to.

• Doing nothing. Gingivitis continues if hygiene does not improve, and it can progress to periodontitis. In periodontitis, the supporting tissue that has been lost largely does not grow back. For recession without signs of disease, monitoring is an option.
• Improving oral hygiene. This is the core treatment for gingivitis. Brushing and cleaning between the teeth are planned for you; risk factors such as smoking and diabetes are addressed.
• Professional cleaning (scale and polish). Plaque and tartar above the gum line are cleaned off. Tartar does not dissolve at home; it comes off only with a professional cleaning⁵.
• Deep cleaning (cleaning below the gum; in Turkey often called küretaj). In periodontitis, plaque and tartar that have built up in the pockets below the gum are cleaned away. The details are on the deep cleaning and root planing page.
• Periodontal surgery. This is considered for pockets that stay deep after deep cleaning. Where the bone loss is suitable, regenerative surgery can also be done.
• Gum graft. Tissue taken from elsewhere in the mouth, or a ready-made material, is placed to cover an exposed root surface.
• Extracting a tooth that cannot be saved. In advanced disease, some teeth may not be saveable. Which teeth can be kept is decided after the examination and measurements.
• Supportive care. After treatment for periodontitis, regular check-ups and cleaning are part of the treatment.

What surgery would gain you is discussed based on the pockets measured at the re-assessment. Additional antibiotics or laser are not among the topics we give sources for on this page; if they are suggested, ask your dentist why.

The European Federation of Periodontology's guideline describes treatment for periodontitis in four steps¹⁰. After each step the gums are re-assessed to see whether the next one is needed. For gingivitis, treatment often stops at the first step. How many appointments you need is planned after the examination.

If it is not treated

• Loss of supporting tissue. As periodontitis progresses, the bone that holds the tooth breaks down; teeth can become loose and be lost. This loss is irreversible¹, but the disease can be stopped with treatment.

Risks and side effects of treatment

• Sensitivity and gums that look receded. As the inflammation settles and the swelling goes down, the gum margin can sit lower. Exposed root surfaces can be sensitive to hot and cold. We cannot say on this page how often this happens. For dentine sensitivity, toothpastes containing stannous fluoride or arginine are recommended among the first options¹¹. This recommendation is based on studies of dentine sensitivity in general; it is not specific to the period after gum treatment.
• Air escaping into the tissues (emphysema). Air escaping into the tissues during dental treatment is an infrequently reported complication¹². The case reports include tooth cleaning and air-polishing. Swelling that appears suddenly after treatment and crackles when touched should be checked straight away.
• Surgery and grafts. Like any surgical procedure, they can cause pain, swelling and bleeding. On a root surface covered with a graft, the gum margin can show a tendency to recede again over time¹³.
• Chlorhexidine mouthwash. It is used only for a short time. Used for 4 to 6 weeks, it stains the teeth¹⁴; altered taste and irritation inside the mouth have also been reported.

Benefits

• Gum health can be restored⁸ with treatment, and periodontitis can be brought under control.
• In people with periodontitis and diabetes (mostly type 2), gum treatment lowered HbA1c by 0.43 percentage points on average¹⁵ at 3 to 4 months; HbA1c is the long-term measure of blood sugar. This result is based on 30 studies and 2,443 participants, and the certainty of the evidence is moderate. Gum treatment does not replace diabetes treatment.

Heart and blood vessel disease

A strong statistical association¹⁶ has been reported between periodontitis and heart and blood vessel disease. This is not evidence of cause and effect. There is not enough evidence to support or rule out the idea that gum treatment prevents heart attack or stroke.

Pregnancy

Bleeding gums are common in pregnancy. In an analysis that pooled 20 studies, gum bleeding was found at examination in about 67 in every 100¹⁷ pregnant women. Gum treatment in pregnancy is safe and improves the condition of the gums¹⁸. The American College of Obstetricians and Gynecologists also considers dental treatment safe¹⁹ in pregnancy, including examinations, dental X-rays and local anaesthetic; putting treatment off can let problems grow. Guidelines differ²⁰ on whether a lead apron or thyroid collar is needed for dental X-rays in pregnancy.

In observational studies, gum disease in pregnancy has been linked with a small increase in the risk of premature birth²¹; this link does not show that gum disease causes premature birth. Gum treatment has also not been shown to prevent premature birth: across 11 studies of 5,671 pregnant women, no clear difference was found²² in the rate of premature birth. The quality of this evidence is low.

In the first days after a deep cleaning or surgery, the gums can be tender and bleed a little. Bleeding that does not stop, or pain and swelling that keep getting worse, are not normal; contact your dentist. For what to expect after a deep cleaning, see the deep cleaning page.

If you have had surgery or a graft, that area needs different care. Follow the written instructions your dentist gives you on when and how to brush it; keep up your daily care in the rest of your mouth.

Daily care

• Brush your teeth at least twice a day with a fluoride toothpaste. After brushing, spit the toothpaste out and do not rinse² your mouth with water.
• For most people, a toothbrush with a small head and medium bristles²³ is suitable. Both electric and manual toothbrushes are effective at controlling plaque. Electric toothbrushes reduced plaque and gingivitis slightly more²⁴; the clinical importance of the difference is unclear.
• Clean between your teeth every day. Dental floss or interdental brushes, used in addition to brushing, may reduce²⁵ gingivitis and plaque; the certainty of the evidence is low. For people who have been treated for periodontitis, interdental brushes are recommended as the first choice¹⁰; floss is an option where the brush does not fit.
• Use chlorhexidine mouthwash only if your dentist recommends it, and only for a short time.
• If you smoke, ask for support to stop.

After treatment for periodontitis, gum health can be restored. But in someone who has been treated, the risk of the disease coming back remains increased⁸, and it needs close monitoring. The European guideline recommends a supportive care interval of at least 3 and at most 12 months¹⁰, depending on the person's risk. This interval is for people who have been treated for periodontitis; for healthy gums, your dentist sets the check-up interval separately.

Bone destroyed by periodontitis largely does not grow back. The aim of treatment is to stop the loss and keep the remaining teeth.

In 40 studies that followed gum grafts for at least 5 years, the gum margin tended to recede again over time¹³. After a graft, keep up your daily cleaning and go to your follow-up appointments.

See a dentist if you have any of the following:

• Gums that bleed when you brush or eat hard food
• Sore or swollen gums
• Bad breath that does not go away

Get an urgent appointment² if:

• Your gums are very painful and swollen
• Your teeth are loose or falling out
• You have a sore or red area in your mouth, or swelling of the lip or inside the mouth
• Your child's gums are painful and bleeding

Swelling that appears suddenly after dental treatment and crackles when touched should be checked without waiting¹²; if you cannot reach your dentist straight away, go to a hospital emergency department.

Emergencies. The following need urgent medical help²⁶. Do not wait for a dental appointment; go to a hospital emergency department or call 112:

• Swelling that makes it hard to breathe, speak or swallow
• Swelling of the eye or the neck²⁷, a painful eye, or sudden problems with your eyesight
• A lot of swelling inside the mouth
• Finding it hard to open your mouth

This page does not give prices. Your treatment plan is prepared for you after the examination. The main factors that shape the plan are:

• The stage of the disease and how many areas need treatment
• Whether you need only a professional cleaning, a deep cleaning, or surgery or a graft
• X-rays, if needed
• The number of re-assessment and supportive care appointments

Ask for the plan in writing, showing what is included and which procedures will be assessed separately.