Introduction

Many people have inflamed gums every now and then. A gum inflammation (gingivitis) usually doesn’t cause any major problems at first. But it may spread to other parts of the periodontium (the soft tissue and bone responsible for keeping our teeth firmly anchored) and cause damage there. The medical term for inflammation of the periodontium is periodontitis. Over time, periodontitis can cause teeth to loosen.

Good oral hygiene can help to prevent gingivitis. Only if you clean your teeth properly can treatment by a dentist stop – or at least slow down – the progression of periodontitis. It’s also very important to carry on taking good care of your teeth after having treatment, in order to prevent periodontitis from getting worse.

Symptoms

The main signs of gingivitis are red, swollen and bleeding gums. The gums bleed when you clean your teeth, and sometimes for no obvious reason too. Gingivitis generally doesn’t cause any pain or other symptoms, so it remains undetected for quite some time.

Periodontitis often doesn’t cause any symptoms either until it has become advanced. As well as red and bleeding gums, it can also lead to sensitive teeth and receding gums (“long teeth”), sore gums and bad breath. If the gums are inflamed, they may start pulling away from the neck of the tooth. This causes gaps to form between the teeth and the gums, known as gum pockets (or periodontal pockets). At a more advanced stage, periodontitis can cause teeth to shift position, start wobbling or hurt when you chew.

Causes

The most common cause of inflamed gums is plaque. Plaque is a thin film that is mainly made up of bacteria and is hardly visible at first. It is mainly found where the tooth and gum meet, and may feel a bit “furry” when you run your tongue over it. The bacteria in the plaque “eat” sugars in food in your mouth, and their waste products can cause the gums to become inflamed and swollen. You can get rid of plaque by cleaning your teeth properly. In other words, good oral hygiene can reduce the risk of gingivitis and periodontitis.

The likelihood of developing gingivitis and periodontitis is also increased by various factors, including

• smoking,
• metabolic diseases such as diabetes, and
• hormonal changes during pregnancy.

Some people are generally more prone to gum disease, too. Certain medications might cause the gum to get bigger, making it harder to clean the teeth properly and increasing the risk of gum disease. Examples include medications that suppress the immune system and medications for cardiovascular (heart and blood vessel) disease.

Outlook

Gingivitis sometimes goes away again. But it might also last a long time, progress and develop into periodontitis.

If gingivitis persists, the pockets between the teeth and gums might become deeper, sometimes even up to 1 centimeter deep. Bacteria start growing in these gum pockets, and it's no longer possible to reach the bacteria with a toothbrush. A layer of bacterial plaque builds up on the root and neck of the tooth, where it may harden. Known as tartar (or calculus), this hard substance can only be removed by a dental professional. If it’s below the gum line it’s known as “subgingival” calculus, and above the gum line it’s called “supragingival” calculus. The deeper the gum pocket, the further the bacterial plaque can spread down towards the bottom of the root of the tooth.

Bacteria and tartar in the gum pockets can cause further inflammations. In periodontitis, the inflammation attacks the soft tissue and bone that supports the teeth and keeps them in place. If it gets worse, it may also attack and break down the jawbone around the teeth. This can expose a part of the roots of the teeth. Over time, the teeth may become loose, making it harder or painful to chew. If that happens, they might have to be removed.

Periodontitis progresses in episodes: There are short phases where tissue is destroyed, and longer phases where the disease doesn’t progress, or where the tissue even recovers a bit. But periodontitis doesn’t go away again on its own.

Diagnosis

One way to detect gum disease is by having a dental check-up. In Germany, statutory health insurances cover the costs of general dental check-ups twice a year, where the dentist inspects the teeth and gums.

The insurers also pay for a screening test for periodontitis (called periodontal screening and recording) once every two years. Here your mouth is checked tooth by tooth for possible gum pockets using a special instrument called a periodontal probe. The dentist also looks for signs of bleeding, tartar (calculus), receding gums, and loose teeth.

If the dentist suspects that you might have periodontitis, other examinations will be necessary – for example, x-rays to find out whether any bone tissue has been broken down.

Prevention

If plaque is not removed, the gums can become inflamed within just a few days. And plaque can harden and develop into tartar.

Although plaque forms very quickly, you can easily remove it by cleaning your teeth regularly and thoroughly – using an interdental brush or dental floss too. A dentist or dental hygienist can show children and teenagers how to clean their teeth properly. German statutory health insurers cover the costs of this patient education in young people under the age of 18.

Tartar can only be removed by dental professionals – for instance, during the regular dental check-ups. In Germany, statutory health insurances cover the costs of having tartar removed once a year. People in need of nursing care and people who have a disability can have tartar removed twice a year without having to pay for it. They can also have two free patient education sessions per year to learn how to clean their teeth and dentures properly.

Dentists often ask if you would like to have professional teeth-cleaning to remove plaque and tartar. But you will usually have to pay for this yourself.

Treatment

Good oral hygiene is very important. If you don’t clean your teeth properly, treatment for periodontitis won’t be effective. People who have gingivitis or periodontitis will be shown in their dental practice how to take good care of their teeth. Adults usually have to pay for this patient education themselves. Before the periodontitis treatment is started, dentists often recommend having professional teeth-cleaning first. You also have to pay for this yourself.

Treatment for gingivitis includes removing tartar and – if necessary – any edges of fillings and crowns that protrude. This is done because it's harder to remove bacterial plaque from behind these edges.

If periodontitis has developed, the bacterial plaque and hard tartar are removed, including the deposits found below the gum line. This is known as scaling and root planing, or “deep cleaning.” If this treatment doesn't help enough, dentists sometimes recommend surgery to clean the surface of the root of the tooth.

The earlier periodontitis is detected, the easier it is to keep it under control. Periodontitis treatment aims to stop the disease from getting worse, preventing more damage and loss of teeth.

Further information

Many people go to the dentist regularly for check-ups rather than just when they have acute toothache. Read about how to find the right dentist, how to prepare for the appointment and what to remember.

Sources

• Deutsche Gesellschaft für Parodontologie (DG PARO), Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK). Häusliches mechanisches Biofilmmanagement in der Prävention und Therapie der Gingivitis (S3-Leitlinie). AWMF-Registernr.: 083-022. November 2018.
• Gemeinsamer Bundesausschuss (G-BA). Richtlinie des Gemeinsamen Bundesausschusses für eine ausreichende, zweckmäßige und wirtschaftliche vertragszahnärztliche Versorgung (Behandlungsrichtlinie). March 1, 2006.
• Gemeinsamer Bundesausschuss (G-BA). Richtlinie des Gemeinsamen Bundesausschusses über Maßnahmen zur Verhütung von Zahnerkrankungen bei Pflegebedürftigen und Menschen mit Behinderungen (Richtlinie nach § 22a SGB V). July 1, 2018.
• Gemeinsamer Bundesausschuss (G-BA). Richtlinien des Bundesausschusses der Zahnärzte und Krankenkassen über Maßnahmen zur Verhütung von Zahnerkrankungen (Individualprophylaxe). June 4, 2003.
• Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Assessment of the systematic treatment of parodontopathies; Commission N15-01. March 5, 2018. (IQWiG reports; Volume 602).
• Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet 2005; 366(9499): 1809-1820. [PubMed: 16298220]
• Torpy JM, Burke AE, Glass RM. Periodontal Disease. JAMA 2008; 299(5): 598. [PubMed: 18252890]
• Zitzmann NU, Ramseier CA, Weiger R, Walter C. Parodontitis. Schweiz Med Forum 2013; 13(9): 183-186.

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  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

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