Gum disease, also known as gingivitis, affects up to nine out of 10 people to some extent. The good news is it can be treated and prevented with diligent oral hygiene regimen, says Steve Titmarsh…

Left unchecked, gingivitis can develop into periodontitis, which can threaten more serious symptoms and lasting damage to teeth and gums.

Failure to brush and floss teeth regularly is one of the commonest causes of gingivitis, or gum disease – a mild form of periodontal disease. Around half to 90 per cent of the population are thought to have some degree of gingivitis.¹

Failure to keep teeth clean allows a build-up of plaque, a film-like substance consisting mostly of bacteria, saliva, food debris and dead cells. Plaque builds up between the gums and teeth, in faulty fillings as well as around teeth next to poorly cleaned partial dentures, bridges, and orthodontic appliances.

Plaque that is not removed within three days can develop into tartar (calculus – formed of plaque that has absorbed calcium and phosphate minerals from saliva).^1,2 The deposit is not removed by brushing and flossing, and requires professional cleaning by a dentist or dental hygienist using specialist tools.

Smoking or chewing tobacco, alcohol use and some disorders such as diabetes and cardiovascular disease are risk factors for periodontal disease. Some drugs are also implicated.

For example, antidepressants and other drugs that cause dry mouth and drugs such as calcium-channel blockers that cause gingival overgrowth.³ Older people are at higher risk, as are those with a poor diet or who are immunocompromised. Stress and pregnancy also increase the risk.¹

Left untreated, gingivitis caused by plaque can progress to periodontitis in most people. Periodontitis is characterised by chronic inflammation that affects the supporting tissue around teeth and causes irreversible damage that can result in teeth eventually falling out.¹

Healthy gums ... or not?

Healthy gums are pink or pigmented and firm with no redness or swelling. They do not bleed when examined with a periodontal probe along the gingival crevice or sulcus (the small gap – less than 3mm in healthy gums – where the teeth meet the gums).⁴

In the early stages mild gingivitis is usually symptomless. The main symptoms, when they do occur, are usually seen in moderate disease. They include

• inflammation – reddening and swelling – of the gum (gingiva) margins
• gums bleeding when brushing teeth, flossing or with gentle probing, and sometimes in more severe cases, after eating especially hard food.^2,4

The inflammation is the result of an immune response to bacterial products and toxins. Gum discomfort is rare.¹

People with periodontitis have halitosis, a foul taste in the mouth, recession and root sensitivity, and drifting or loosening of teeth that makes eating difficult and periodontal abscess that may be painful.⁴

Treatment and prevention

To help prevent gum disease teeth should be brushed for two minutes twice a day (see Box 1 for tips on technique). There is no high-quality evidence on which time of day is best to brush so the advice is that it should ideally be done once during the day and again at night just before going to bed.

A powered toothbrush is recommended, but a manual toothbrush can be equally effective for removing plaque.⁵ It should have a small brush head (small enough to enable the user to reach right to the back of the mouth) with medium texture, multi-tufted, and preferably, some say, round-ended nylon bristles. The brush should be replaced every one to three months when it shows signs of wear.^1,6

For children over three years old and adults it is best to use a fluoride-containing toothpaste (usually containing 1,350–1,500ppm fluoride)^6,7 and to not rinse the mouth after brushing – just spit.¹ Rinsing the mouth straight after brushing washes away any residual fluoride, reducing the benefit for preventing caries.⁷

Cleaning with an interdental aid (for example, floss or an interdental brush) before brushing teeth is recommended.¹ It is not advisable to use toothpicks between the teeth as they are usually too hard and can damage gum tissue.⁷ Some people may benefit from using a disclosing agent to reveal areas of the mouth that have not been brushed to help improve their technique.⁵

Routine use of mouthwash is not necessary.¹ If a mouthwash is used there is good evidence for the effectiveness of chlorhexidine-containing formulations on plaque removal when used in conjunction with toothbrushing and interdental cleaning.

However, it is not advisable to use these mouthwashes for long period of time (four weeks or more) because of the risk of tooth staining and adverse effects such as calculus build up, transient taste disturbance and temporary damage to the mouth lining.⁸

Avoiding brushing teeth after using chlorhexidine mouthwash and avoiding tannin-containing drinks (for example, tea, coffee, red wine) within two to three hours of using the mouthwash can help reduce staining. Using a 0.2 per cent solution rather than higher concentration formulations can also help reduce staining.²

Maintaining good oral hygiene, along with regular visits to a dentist, will help reduce the risk of developing gingivitis. In addition a good diet, such as that suggested in the UK Government’s Eatwell Guide, is beneficial.⁹  This encourages eating a range of healthier more sustainable food, with more fruit and vegetables and fewer sugar-containing drinks and fruit juices and/or smoothies,

In some cases people with risk factors such as diabetes frequent professional teeth cleaning may be needed.¹

Brushing technique^6,7

• Pay particular attention to the gumline, areas around crowns, fillings or restorations and hard-to-reach areas at the back of the mouth
• Brush all teeth surfaces – inner, outer and chewing
• Start by placing the brush head at a 45-degree angle against the gum and brush in a circular motion away from the gumline. Follow that with short back and forth strokes to gently brush all surfaces
• It may help to imagine the mouth in four sections (eg left side top and bottom and right side, top and bottom) and spend 30 seconds cleaning each section to achieve a total of two minutes brushing time
• Flossing before brushing is a good way to dislodge food that can then be brushed away

References 

1. Clinical Knowledge Summaries. Gingivitis and periodontitis (https://cks.nice.org.uk/topics/gingivitis-periodontitis; accessed October 2022).
2. Patient.info. Dental Plaque and Gum Disease (https://patient.info/oral-dental-care/toothache/dental-plaque-and-gum-disease; accessed October 2022).
3. Office for Improvement & Disparities. Delivering better oral health: an evidence-based toolkit for prevention. Chapter 5: Periodontal disease (www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases; accessed October 2022).
4. Rathee M, Jain P. Gingivitis. Stat Pearls (www.ncbi.nlm.nih.gov/books/NBK557422; accessed October 2022).
5. Office for Improvement & Disparities. Delivering better oral health: an evidence-based toolkit for prevention. Chapter 8: Oral hygiene (www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene; accessed October 2022).
6. Oral Health Foundation. Caring for my teeth and gums (www.dentalhealth.org/caring-for-my-teeth; accessed October 2022).
7. NHS inform. Teeth cleaning guide (www.nhsinform.scot/healthy-living/dental-health/your-teeth/teeth-cleaning-guide#the-toothpaste; accessed October 2022).
8. James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database of Systematic Reviews 2017;3:CD008676.
9. GOV.UK. The Eatwell Guide (www.gov.uk/government/publications/the-eatwell-guide; accessed October 2022).