Mild gum disease, known as gingivitis, can be controlled with good oral hygiene but left unchecked can develop into a more serious form – periodontitis – which may threaten the structures that keep teeth in place, writes Steve Titmarsh...

Gingivitis, or inflammation of the gums, is a mild form of periodontal or gum disease. It may resolve on its own without any intervention or just stay as a mild disorder for years. However, left untreated gingivitis can lead to periodontitis, which is more serious. Good dental hygiene can control gingivitis and the problems that may ensue.1

Signs and symptoms of gingivitis include:1

• Red and swollen gums

• Gums bleeding when brushing or flossing2

• Gums are tender to the touch but not painful otherwise

• There may be mouth sores

• Gums may appear shiny

• It is not usually painful

The risk of developing gingivitis can be increased by factors such as poor dental hygiene; pregnancy, when hormonal changes increase gum sensitivity; uncontrolled diabetes; misaligned teeth; some medicines, eg phenytoin, nifedipine and some oral contraceptives, as well as a poor diet.3

Causes and effects

In people with poor oral hygiene plaque builds up between the teeth and gums (gingiva) to create gingival pockets – these pockets contain bacteria that can cause gingivitis and lead to caries.1 Indeed, a build-up of dental plaque is the most common cause of gingivitis.4

Plaque consists of a sticky film covering the teeth.5 It contains bacteria that metabolise sugars in our food to produce acids. The presence of acid lowers the pH in the mouth, which encourages demineralisation of tooth enamel and creates favourable conditions for the proliferation of bacteria such as Streptococci mutans and Lactobacilli that are known to be associated with demineralisation of the protective enamel around the teeth. This can lead to dental caries and gingivitis.1,6

Swelling of the gums can also happen during pregnancy when the gums can become more vulnerable to plaque and may bleed.7 

Another form of mild gum disease known as non-plaque-induced gingivitis is relatively rare, only affecting a small proportion of the population. It can be caused by infections, allergic reactions, trauma, mucocutaneous disorders such as lichen planus and pemphigoid, and some genetic disorders.1 

Left unchecked, gingivitis can progress with the development of a build-up of tartar (also known as calculus), a hardened accumulation of plaque at the gum line, and this may lead to periodontitis,8 in which inflammation spreads other parts of the soft tissue and bone that keep teeth firmly in place. Periodontitis is a more serious because over time it can cause teeth to become loose.9 

Periodontitis is symptomless in the early stages. When it is more advanced it can cause sensitive teeth, receding gums, sore gums and bad breath. Gaps between the teeth and gums known as periodontal pockets can develop where bacteria can grow, and in advanced stages of periodontitis teeth can shift position and wobble or hurt when chewing. Bacteria growing in periodontal pockets cannot be reached with a toothbrush, so professional cleaning by a dentist or hygienist is needed to remove the calculus.9

Keeping gums healthy

A number of strategies will help keep gums healthy and therefore help to prevent gum disease from developing.10 Key among these is good oral hygiene, especially brushing the teeth, and regular visits to a dentist. Fluoride in toothpaste helps stop the production of plaque acid by reducing the fall in pH that results from sugar metabolism in plaque biofilms.6 So brushing the teeth twice a day with a fluoride toothpaste can help keep teeth and gums healthy.

Correct brushing technique is important to make sure teeth are cleaned properly. A dentist can demonstrate the correct technique for using a manual toothbrush. It is recommended to spend about two minutes brushing teeth just before going to bed and then again at some point during the day, every day. All teeth surfaces need to be cleaned.

It is best not to rinse the mouth immediately after brushing the teeth because the fluoride remaining in the toothpaste is washed away. It is best to just spit out any excess toothpaste.11 Similarly, it is not a good idea to use mouthwash straight after brushing teeth. It is better to use a mouthwash at a different time from brushing teeth such as after lunch, and you should not eat or drink for half an hour afterwards.12

In terms of which type of manual toothbrush to use, most adults will find a toothbrush with a small compact head and bristles with short, rounded ends a good choice.12

Toothpaste should contain at least 1350 parts per million (ppm) of fluoride. Children can use the family toothpaste as long as it contains 1350–1500 ppm fluoride. Children younger than six years old who have no tooth decay can use toothpaste with less fluoride in as long as it contains at least 1000ppm. 

A smear of toothpaste is enough for children under six years old to clean their teeth with, and a pea-sized blob is sufficient for children aged three to six years. They must not be allowed to lick toothpaste straight from the tube though.12

Regular flossing is recommended to remove plaque from between the teeth.12

Avoiding sugary foods and drinks between main meals and regular check-ups at the dentist where teeth can be professionally cleaned are also advisable. 

Stopping smoking is recommended because smoking, along with conditions such as diabetes, as well as stress, are associated with an increased risk of gum disease.13

Stimulating saliva production after main meals could help plaque pH levels to return to normal more quickly. There is some suggestion that chewing sugar-free gum immediately after meals may reduce caries, although more research is needed to confirm the finding.14

Toothbrushes: manual versus electric

Evidence as to which type of toothbrush for cleaning teeth might be superior – manual or electric – is presented in a 2014 Cochrane review. It considered 51 trials involving 4,624 participants in an effort to determine which method of brushing was best for plaque removal and gum health. The review included randomised controlled trials that lasted for at least four weeks and involved adults and children cleaning their teeth unsupervised. A range of different electric toothbrushes were used by participants, including those with side-to-side action, counter oscillation, rotation oscillation and circular as well as those using ultrasonic, ionic, and unknown mechanisms. 

The researchers found moderately good evidence of a significant benefit from using electric toothbrushes over manual in terms of reducing plaque and the development of gingivitis. Compared with using a manual toothbrush, among people using an electric toothbrush there was an 11 per cent reduction in plaque after one to three months’ use and a 21 per cent reduction after three months.

There was a 6 per cent reduction in gingivitis after one to three months and an 11 per cent reduction after three months’ use of an electric toothbrush. Nevertheless the authors note that choice of the type of toothbrush is personal and brushing with a manual toothbrush is still and effective way to protect teeth and gums.15

Interdental devices such as floss, wooden cleaning sticks, interdental brushes and oral irrigators used alongside tooth brushing were also investigated by Cochrane. The review looked at 35 randomised controlled trials involving 3,929 adults. The evidence suggests that using an interdental brush as well as a toothbrush to clean teeth may reduce plaque and gingivitis. Flossing as well as brushing teeth may reduce gingivitis. However, the studies were short-term and involved people with a low level of gingivitis at the start, and the evidence is of low to very low certainty, the authors comment.16

References 

1. www.msdmanuals.com/professional/dental-disorders/periodontal-disorders/gingivitis (accessed 16 July 2020).

2. https://medlineplus.gov/ency/article/001056.htm (accessed 14 July 2020).

3. https://medlineplus.gov/ency/article/001056.htm (accessed 14 July 2020).

4. www.medicalnewstoday.com/articles/241721#causes (accessed 14 July 2020).

5. www.mouthhealthy.org/en/az-topics/p/plaque (accessed 14 July 2020).

6. Marsh PD. Dental plaque as a biofilm and a microbial community – implications for health and disease. BMC Oral Health 2006;6(Suppl 1):S14.

7. www.nhs.uk/conditions/pregnancy-and-baby/teeth-and-gums-pregnant (accessed 14 July 2020.)

8. www.ncbi.nlm.nih.gov/books/NBK554695 (accessed 16 July 2020).

9. www.ncbi.nlm.nih.gov/books/NBK279593 gingivitis (accessed 16 July 2020).

10. www.nidcr.nih.gov/health-info/gum-disease/more-info (accessed 16 July 2020).

11. www.dentalhealth.org/news/spit-dont-rinse-for-better-oral-health

12. www.nhs.uk/live-well/healthy-body/how-to-keep-your-teeth-clean

13. www.cdc.gov/oralhealth/conditions/periodontal-disease.html

14. Mickenautsch S, Leal SC, Yengopal V, et al. Sugar-free chewing gum and dental caries – a systematic review. Journal of Applied Oral Science 2007;15(2):83–8.

15. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD002281.

16. Worthington HV, MacDonald L, Poklepovic Pericic T, et al. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD012018.