Gum Disease (Gingivitis)

  • Medical Author:
    Steven B. Horne, DDS

    Dr. Steve Horne began his career at Brigham Young University obtaining his BA in English. He earned his doctorate of dental surgery in 2007 from the University of Southern California where his pursuit for academic excellence landed him on the dean's list. He was recognized for his superior clinical skills and invited to help teach other dental students in courses on restorative dentistry, prosthodontics, and tooth anatomy. During dental school, he provided dental care for underserved populations of Los Angeles and Orange County, Mexico, and Costa Rica with the international volunteer organization AYUDA. After graduation from USC, Dr. Horne entered active duty with the U.S. Army and practiced dentistry at Fort Knox, Kentucky, for four years. During this time, in 2010, he was deployed as part of a medical unit to Baghdad, Iraq, to provide dental and triage support to military and civilian workers who were involved in the effort there. During his military service, he received multiple Army Achievement Medals, the Army Commendation Medal, and served as company commander. After leaving the Army in 2011, Dr. Horne joined a private practice in La Jolla, Calif., and became credentialed with Scripps Memorial Hospital La Jolla as a dental consultant. Health and education are of paramount importance to Dr. Horne, and since 2012, he has been writing dental articles for MedicineNet and WebMD to provide accurate information about oral health to the public. He is a member of the American Dental Association (ADA), Academy of General Dentistry (AGD), California Dental Association (CDA), and the San Diego County Dental Society and American Academy of Cosmetic Dentistry (AACD). He is a preferred provider with Invisalign and spends countless hours each year pursuing continuing education in order to maintain a standard of excellence in dentistry. Dr. Horne has been married for 15 years to his wife, Christy. They have 3-year-old twins, Camille and Trent, and very recently welcomed their third child, Colette Elise, on July 6! The heart and soul of the family is Roscoe, their chocolate Labrador.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

Shocking Diseases of the Mouth

What is gum disease (gingivitis)?

Gum disease, or gingivitis, is inflammation of the tissues surrounding and supporting the teeth and is most commonly a result of poor dental hygiene. Gingivitis is a very common condition and varies widely in severity. It is characterized by red, swollen gums that bleed easily when teeth are brushed or flossed. Gingivitis is not the same thing as periodontitis, although sometimes a person may be affected by both.

What is the difference between gingivitis and periodontal disease?

While gingivitis is inflammation of the gums around the teeth, periodontal disease occurs when the bone below the gums gets inflamed or infected.

Gingivitis starts when food debris mixes with saliva and bacteria-forming plaque that sticks on the surfaces of teeth. If dental plaque and tartar aren't removed by brushing with toothpaste and flossing, it can become mineralized and form tartar, or calculus. Tartar is very hard and can only be removed by a professional dental cleaning.

Both dental plaque and tartar are filled with harmful bacteria, and if they aren't removed from teeth, they will begin to irritate the gums and cause gingivitis. If left untreated, gingivitis will often extend from the gums to the bone and lead to periodontitis. When the underlying bone gets infected, it will start to recede away from the teeth and form deep gum pockets. These pockets collect plaque and bacteria as they are very difficult to keep clean, and more bone loss occurs. As periodontal disease progresses into later stages and more bone tissue is lost, the teeth may eventually become loose and fall out.

What causes gum disease?

Gum disease is mostly caused by improper oral hygiene that allows bacteria in plaque and calculus to remain on the teeth and infect the gums. But there are other factors that increase the risk of developing gingivitis. Some of the most common risk factors are as follows:

  • Smoking or chewing tobacco prevents the gum tissue from being able to heal.
  • Crooked, rotated, or overlapping teeth create more areas for plaque and calculus to accumulate and are harder to keep clean.
  • Hormonal changes in puberty, pregnancy, and menopause typically correlate with a rise in gingivitis. The increase in hormones causes the blood vessels in the gums to be more susceptible to bacterial and chemical attack. At puberty, prevalence of gum disease ranges between 70%-90%.
  • Cancer and cancer treatment can make a person more susceptible to infection and increase the risk of gum disease.
  • Alcohol affects oral defense mechanisms.
  • Stress impairs the body's immune response to bacterial invasion.
  • Mouth breathing can be harsh on the gums when they aren't protected by the lips, causing chronic irritation and inflammation.
  • Poor nutrition, such as a diet high in sugar and carbohydrates and low in water intake, will increase the formation of plaque. Also, a deficiency of important nutrients such as vitamin C will impair healing.
  • Diabetes mellitus impairs circulation and the gums ability to heal.
  • Medications such as antiseizure medications promote gum disease.
  • Infrequent or no dental care
  • Poor saliva production

Does gum disease cause bad breath?

Bad breath, or halitosis, is most frequently associated with a condition of the mouth like gum disease. As the bacteria that are normally present in the mouth break down plaque and tartar, they release chemicals that have a strong odor. Bad breath can also come from plaque that builds up on the tongue. As the plaque and tartar are removed from the teeth and tongue with regular brushing, flossing, and professional dental cleanings, the halitosis can be eliminated. This is the easiest way to reverse bad breath, but it can take a while for the mouth odor to completely disappear. A person needs to be consistent and persistent with oral hygiene to reverse the condition.

Other causes of bad breath include partially erupted wisdom teeth, dry mouth, mouth breathing, postnasal drip, infections in the throat or lungs, tonsil stones, smoking, digestive problems, and systemic diseases like diabetes.

Quick GuideThe Ugly Truth About Your Toothbrush & Germs

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Gingivitis Symptoms and Signs

Bleeding Gums

Bleeding of the gums is sometimes referred to as gingival bleeding, and it may occur during brushing or flossing. The soreness can be accompanied by swelling of the gum tissues. Most commonly, gingivitis is the result of plaque buildup on the teeth around the gum line.

What does gum disease look like? What are gum disease symptoms and signs?

A person with gingivitis will typically have one or more of the following signs and symptoms:

  • Bright red, swollen gums that bleed very easily, even during brushing or flossing
  • A bad taste or mouth odor
  • White spots or plaques on the gums
  • Gums that look like they're pulling away from the teeth
  • Pus between gums or teeth
  • A change in the way the teeth fit together in the mouth or spaces opening up between teeth
  • Change in the way partial dentures fit

As gingivitis progresses (chronic gingivitis), various complications may arise. The affected person may develop receding gums or areas where the root of the tooth becomes uncovered by the shrinking, diseased gums. Deep pockets may develop around the teeth that trap food, plaque, and debris. If gingivitis advances to periodontal disease, the person may lose gum tissue or bone around the teeth and the teeth may become loose or fall out. These changes can develop either very slowly or very rapidly and can affect either a few teeth or the entire mouth. If oral hygiene is almost never done or if the person becomes immune-compromised, acute necrotizing ulcerative gingivitis may develop (ANUG, formerly termed trench mouth). This is a painful condition where infected gums swell, ulcerate, and slough off dead tissue.

It is possible to have gingivitis and not notice any signs or symptoms, so regular visits to the dentist are vital in determining a patient's specific risk level. The dentist is the primary-care provider of the mouth and will be able to provide all of the facts and information necessary in diagnosing the disease and taking steps in curing or reversing gum disease.

How do health-care professionals diagnose gum disease?

The following methods and symptoms are very useful in the diagnosis of gum disease:

  • Measuring the gums: A dentist or hygienist will use a periodontal probe to measure the depths of the pockets around all of the teeth in the mouth generally once per calendar year. Healthy gums will have pockets 1 mm-3 mm deep. Beyond that, the deeper the pockets, the more severe the disease.
  • Taking X-rays: Dental bitewing X-rays will help show the level of the underlying bone and whether any bone has been lost to periodontal disease.
  • Examining sensitive teeth: Teeth that have become sensitive around the gum line may indicate areas of receding gums.
  • Checking the gums: A dentist or hygienist will look for red, swollen, or bleeding gums.

What is the treatment for gum disease?

The treatment goals for gingivitis are to identify and eliminate the factors that are making the person more susceptible to gum disease. Most factors can be eliminated by establishing more consistent and thorough oral hygiene habits and professional dental cleanings. If there are certain risk factors such as smoking or uncontrolled diabetes that are contributing to the gum disease, they need to be addressed or eliminated to have success in reversing gingivitis. After the plaque and tartar are removed by a dentist or hygienist, the patient can usually cure gum disease by brushing and flossing after every meal and using a daily mouth rinse. Under the supervision of a dentist, a patient can use 10% carbamide peroxide in a custom made tray that fits over the teeth with positive effects on plaque control and gingival health. This is especially helpful in patients where conventional oral hygiene practices like brushing and flossing are impaired due to age or special needs.

In cases where gingivitis has led to periodontal disease and there are deep pockets that are difficult to clean, the patient may require deep scaling and root planing to clean teeth that are surrounded by deep pockets. They may need surgical treatment to gain access to all the tooth surfaces for a thorough cleaning. This surgical procedure is called flap surgery and can be combined with a pocket-reduction surgery to make the areas around the teeth easier for the patient to clean with brushing and flossing. This procedure consists of numbing the gums and then lifting them back to clean the teeth and sometimes reshape the bone. The gums are then repositioned around the teeth so there aren't the deep pockets that existed before treatment.

Soft-tissue grafts are used to cover up root surfaces that have been exposed by receding gums. This can help eliminate sensitive teeth and protect the root surfaces that are softer and more difficult to clean.

Laser therapy is another treatment to help increase gum health. The gum pocket is treated with a soft tissue laser to eliminate the harmful bacteria deep in the periodontal pockets, remove unhealthy tissue and help stimulate healing.

What types of specialists treat gum disease?

Periodontists are dentists who have completed additional training after dental school focused entirely on the evaluation, diagnosis, and treatment of disease of the gum and bone surrounding the teeth. In advanced cases of gingivitis or periodontal disease, a general dentist may recommend a gross debridement of superficial plaque and tartar and will then refer the affected patient to a periodontist for evaluation. Periodontists may recommend a variety of nonsurgical or surgical procedures to help stabilize the gum condition. Periodontists are also very skilled at performing treatments of other conditions of the gums and bone including gum and bone grafts, functional and esthetic gingivectomy, gingivoplasty, implants, and crown lengthening.

What types of medication are used to treat gum disease?

Antibiotic therapy can be combined in various ways to help treat gingivitis, periodontal disease, and especially ANUG. Chlorhexidine (Peridex) is an antibiotic mouthwash that can be used under direction of a dentist to help reduce the bacteria that cause gum disease. Pellets or gels like PerioChip that contain the antibiotic chlorhexidine or doxycycline can be placed in deep gum pockets after deep scaling and root planing to kill stubborn bacteria and reduce the size of periodontal pockets. These modes of delivering antibiotic therapy are very effective because the antibiotic is released slowly over the course of about seven days. Additional treatment such as xylocaine and NSAIDs may be needed for pain control in chronic gingivitis and ANUG.

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Are home remedies or natural treatments effective for gum disease?

There has been evidence to suggest the effectiveness of the following over-the-counter and natural treatments for gum disease:

  • Green tea has antioxidants that reduce inflammation in the body.
  • Hydrogen peroxide helps kill bacteria when used as a mouthwash or as a gel in a custom fitted tray, but it cannot be swallowed.
  • Warm saltwater rinse reduces inflammation and kills bacteria, but daily use will damage the teeth.
  • Baking soda and water can be used to brush the teeth to help neutralize the acids that can cause gum disease.
  • Oil pulling (swishing or rinsing) -- there has been little evidence to prove that sesame oil or coconut oil can help reduce bacteria that cause gum disease, but this is a popular practice. On a case by case basis, people have noticed improvement with this treatment.
  • In addition, see the section on prevention of gum disease and on toothpaste.

Is it possible to reverse gum disease?

As long as the causes of gum disease are correctly identified and the patient is persistent in improving their oral hygiene and seeking necessary treatment, gum disease can be reversible. The prognosis is best when treatment is obtained in early stages of gingivitis. At this stage, the affected person usually just needs a professional dental cleaning and more thorough brushing and flossing to reverse disease. As the condition turns from acute to chronic (chronic gingivitis), and from gingivitis to periodontitis or to ANUG, the prognosis gets less predictable. Therefore, it is very important to catch and treat gum disease as early as possible.

Is gum disease associated with other health problems?

There have been many attempts to understand the link between gum disease and other systemic health problems such as heart disease, stroke, and Alzheimer's disease. Comparing the bacteria that cause dental plaque with the bacteria involved in heart disease suggests a correlation between gum disease and heart disease, but researchers have been unable to establish a cause and effect relationship. These types of relationships are difficult to prove or disprove, so it is fair to assume that aiming for a life free of gum disease will only help in leading a generally healthier life.

While it may be hard to prove what health problems gum disease directly causes, it is known that certain health problems can cause gum disease. If there are any sudden changes to a person's medical condition, they should ask their primary-care provider or dentist if there might be any effects on oral health. Healthy gums can quickly become threatened when the body's overall health diminishes or changes for any reason.

How is gum disease managed in children?

A child should start having his or her teeth brushed with a pea-sized amount of toothpaste beginning at 12 months of age. As soon as the gaps between the teeth start to close, it is important to start flossing. At the beginning, the parents should establish a routine to brush the teeth so the child can get used to it. As soon as the child is able, the brushing and flossing should be passed over to him or her and monitored by the parent to ensure good thorough technique and consistency. A child should get regular dental visits starting at about 2 years of age. Abiding by these guidelines will effectively prevent and treat gum disease in most children.

It is common for there to be an increase in gingivitis during puberty due to the hormonal changes that occur throughout the body. Adolescents should be monitored for good oral hygiene habits and taken to the dentist regularly to treat gum disease with professional dental cleanings.

How is gum disease managed in pregnancy?

Many women who become pregnant think that they should avoid the dentist to keep their pregnancy safe, but they shouldn't miss their dental cleanings as long as they feel strong and comfortable enough. During pregnancy, women are at risk of developing pregnancy gingivitis. Because of the increase in hormones that occurs with pregnancy, the gum tissues are more susceptible to attack from bacteria and other pathogens. Pregnant women will often notice an increase in swollen, bleeding gums even if their oral hygiene has remained consistent. It may be necessary to get dental cleanings more often than usual during pregnancy to help combat this increased risk.

Quick GuideThe Ugly Truth About Your Toothbrush & Germs

The Ugly Truth About Your Toothbrush & Germs

Is it possible to prevent gum disease?

Prevention of gingivitis and periodontal disease is very simple in most cases. Gum disease is best prevented through proper plaque control. This involves brushing to remove plaque from the outer surfaces of the teeth and flossing to remove food particles and plaque from in between the teeth. Electronic toothbrushes tend to make it easier to remove plaque from some of the harder to reach areas of the mouth. Using a mouthwash after brushing and flossing can also help by reducing the bacteria that cause gingivitis.

Besides these basic oral hygiene practices, there are other things that can be done to eliminate the factors that lead to an increase in gum disease:

  • Sleep/stress: The immune system is very important in controlling disease, and getting adequate sleep and reducing stress will help the body fight gum disease, too.
  • Stop smoking: Smokers are much more likely to develop gingivitis and periodontal disease, so avoiding tobacco should be the first thing someone does to achieve healthy gums.
  • Orthodontic therapy or braces: It is much easier to remove plaque from straight teeth than crowded, overlapped, and crooked teeth. Braces can make a big difference in having healthier gums.
  • Diet: Limiting the frequency of plaque-causing sugars and carbohydrates will help limit plaque. Eating a well-balanced diet will help keep the body's immune system healthy and ready to fight infection.

What is the best toothpaste to use to prevent gum disease?

The goal of toothbrushing is to remove plaque on the teeth that will harbor bacteria and cause gum disease and tooth decay. Just about any toothpaste when used with consistent thorough brushing habits will accomplish this goal. There are some ingredients in toothpastes that help remove plaque more effectively and help keep plaque off the teeth after they have been brushed. The abrasive agents in toothpaste such as silicates and calcium carbonates help remove plaque that is a little sticky. Sodium lauryl sulfate is a detergent in toothpaste that causes the foaming effect of toothpastes. Toothpastes vary in the amount of SLS they contain; a high concentration of SLS can cause problems for patients who have dry mouth or low saliva flow. Some toothpastes include plaque-control agents such as pyrophosphates and zinc citrate that prevent plaque from sticking to the teeth after they've been brushed. Using a toothpaste that contains any combination of these ingredients will increase the effectiveness of oral hygiene.

Furthermore, rinsing with an essential-oil containing dentifrice (mouthwash) for 30 seconds twice daily after brushing helps prevent plaque buildup even more.

Is gum disease contagious?

While most of the factors that lead to gingivitis and periodontal disease are dependent on the individual, there has been some limited scientific evidence to affirm that gingivitis and periodontitis-causing bacteria can be passed down from parents to children and between couples.

REFERENCES:

Asikainan, S., et al. "Can one acquire periodontal bacteria and periodontitis from a family member?" The Journal of the American Dental Association 128.9 (1997): 1263-1271.

Atkinson, Jane C., Anne O'Connell, and Doron Aframian. "Oral Manifestations of Primary Immunological Diseases." The Journal of the American Dental Association 131.3 (2000): 345-356.

Charles, Christine H., et al. "Comparative efficacy of an antiseptic mouthrinse and an antiplaque/antigingivitis dentifrice: A six-month clinical trial." The Journal of the American Dental Association 132.5 (2001): p670-675.

Demmer, Ryan T. and Moise Desvarieux. "Periodontal infections and cardiovascular disease: the heart of the matter." The Journal of the American Dental Association 137 Suppl (2006): 14S-20S.

"Gum Disease." Mouth Healthy. American Dental Association.

Lazarchik, David A., and B. Van Haywood. "Use of Tray-Applied 10 Percent Carbamide Peroxide Gels for Improving Oral Health in Patients With Special-Care Needs." The Journal of the American Dental Association 141.6 (2010): 639-646.

Meraw, S. J. and C. M. Reeve. "A case report: Treating localized refractory idiopathic gingivitis with Superoxol." The Journal of the American Dental Association 129.4 (1998): 470-472.

Neville, Brad W., et al. Oral and Maxillofacial Pathology. 2nd ed. Saunders, 2002.

Snider, J. "Green tea may promote periodontal health." The Journal of the American Dental Association 140.7 (2009) 838.

Stephen, James M. "Gingivitis." Medscape.com. Dec. 31, 2014. <http://emedicine.medscape.com/article/763801-overview>.

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Reviewed on 4/6/2016
References
REFERENCES:

Asikainan, S., et al. "Can one acquire periodontal bacteria and periodontitis from a family member?" The Journal of the American Dental Association 128.9 (1997): 1263-1271.

Atkinson, Jane C., Anne O'Connell, and Doron Aframian. "Oral Manifestations of Primary Immunological Diseases." The Journal of the American Dental Association 131.3 (2000): 345-356.

Charles, Christine H., et al. "Comparative efficacy of an antiseptic mouthrinse and an antiplaque/antigingivitis dentifrice: A six-month clinical trial." The Journal of the American Dental Association 132.5 (2001): p670-675.

Demmer, Ryan T. and Moise Desvarieux. "Periodontal infections and cardiovascular disease: the heart of the matter." The Journal of the American Dental Association 137 Suppl (2006): 14S-20S.

"Gum Disease." Mouth Healthy. American Dental Association.

Lazarchik, David A., and B. Van Haywood. "Use of Tray-Applied 10 Percent Carbamide Peroxide Gels for Improving Oral Health in Patients With Special-Care Needs." The Journal of the American Dental Association 141.6 (2010): 639-646.

Meraw, S. J. and C. M. Reeve. "A case report: Treating localized refractory idiopathic gingivitis with Superoxol." The Journal of the American Dental Association 129.4 (1998): 470-472.

Neville, Brad W., et al. Oral and Maxillofacial Pathology. 2nd ed. Saunders, 2002.

Snider, J. "Green tea may promote periodontal health." The Journal of the American Dental Association 140.7 (2009) 838.

Stephen, James M. "Gingivitis." Medscape.com. Dec. 31, 2014. <http://emedicine.medscape.com/article/763801-overview>.

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