Gingivitis and periodontitis

Page last reviewed: 13/07/2011

Gum disease (also known as gingivitis) and periodontitis, which can follow a case of gum disease, are two conditions that affect the teeth and gums.

Gum disease causes:

  • red and inflamed (swollen) gums
  • bleeding gums when brushing teeth

Gum disease is usually caused by a build-up of plaque on the teeth. Plaque is a sticky substance made up of bacteria. It is usually removed by brushing the teeth but, if it builds up, the bacteria can irritate the gums and cause inflammation (swelling).

Periodontitis

Periodontitis is a more severe form of gum disease. In periodontitis, the inflammation that affects the gums also affects:

  • the tissue that connects the tooth to the tooth socket, called the periodontal ligament
  • the bone in the jaw that contains the sockets of the teeth, called the alveolar bone

Periodontitis can cause a gap to develop between the tooth and the gum, making the tooth feel loose and, in some cases, fall out.

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) is another form of severe gum disease. It used to be called Vincent's gingivitis or trench mouth. ANUG is a painful bacterial infection of the gums that can cause swelling and ulcers (open sores) to develop.

How common is gum disease?

Most people have at least one case of mild gum disease during their lifetime. It is estimated that 50-90% of the adult population has some degree of gum disease.

Aggressive or early-onset periodontitis, where severe periodontitis is present before 35 years of age, affects 1-2% of the population.
 
ANUG is rare and usually only affects people with a weakened immune system (the body's natural defence system) or people who are malnourished (do not eat enough nutrients to maintain good health).

Outlook

A mild case of gum disease can usually be successfully treated with good oral hygiene. This should include brushing the teeth twice a day (in the morning and last thing at night) and flossing at least three times a week.

If gum disease is not treated, it can develop into periodontitis or, in severe cases, ANUG. These conditions can cause more serious complications, such as painful sores, which can destroy parts of the gums, and loose and unstable teeth.

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth and can cause your teeth to become loose and fall out.

Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
 
Plaque
Plaque is a sticky substance that is made up of bacteria. It can build up on your teeth if you do not brush them.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some are good for you.

Ulcers
An ulcer is a sore break in the skin or on the inside lining of the body.

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Page last reviewed: 13/07/2011

A healthy set of gums should be pink and firm, and will keep your teeth securely anchored in place. Your gums should not bleed when you touch or brush them.

Symptoms of gum disease

If you develop gum disease (gingivitis), it is not usually painful, but you may notice:

  • swelling and redness in the gums
  • bleeding gums after you brush or floss your teeth or touch your gums

Symptoms of periodontitis

If you go on to develop periodontitis, you may not notice any symptoms, or the swelling and bleeding of your gums may get worse. Other possible symptoms include:

  • bad breath (halitosis)
  • a foul taste in your mouth
  • receding gums, so that more of your tooth is visible
  • sensitive teeth, for example pain when hot or cold liquid touches your teeth
  • pus coming from the gums
  • loose teeth, which may make eating difficult
  • teeth falling out
  • abscesses (painful collections of pus forming on your gums or under your teeth)

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) is a rare condition. The symptoms are usually more severe than those associated with gum disease and periodontitis. Symptoms of ANUG can come on quickly, and can include:

  • very painful, bleeding gums
  • an excessive amount of saliva in your mouth
  • severe bad breath (halitosis)
  • difficulty swallowing or talking
  • a metallic taste in your mouth
  • a high temperature (fever) of 38C (100.4F) or more
  • feeling generally unwell
  • ulcers on your gums, between your teeth
  • swollen lymph nodes in your neck. The lymph nodes are part of the immune system (the body's defence system) and can swell up when your body is fighting an infection

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth, and can cause your teeth to become loose and fall out.

Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
 
Ulcers
An ulcer is a sore break in the skin or on the inside lining of the body.

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Page last reviewed: 13/07/2011

Gum disease (gingivitis) and periodontitis can be caused by a variety of factors, but the most common cause is ineffective oral hygiene, which leads to a build-up of plaque. Plaque is a soft, sticky substance that is made when bacteria collect on the surface of your teeth.

How plaque builds up

Your mouth is full of millions of tiny bacteria. When you consume food and drink that are high in carbohydrates, such as sugary foods or drinks, the bacteria break the carbohydrates down into acid. The acid then combines with the bacteria, the saliva in your mouth and the small particles of food that are left after brushing, to produce a sticky film called plaque.

Plaque can usually be easily removed by brushing your teeth (twice a day) and flossing (at least three times a week). Sometimes, when plaque is not removed, it can harden and form another substance, known as tartar. Tartar sticks much more firmly to teeth than plaque, and can usually only be removed by a dentist or dental hygienist.

Ineffective oral hygiene

Ineffective oral hygiene can lead to a build-up of plaque and tartar on your teeth. When this happens, the bacteria can cause the gums to become sore and inflamed (swollen), leading to gum disease.

If gum disease is not treated and the plaque and tartar continue to build up, you may develop periodontitis. This can cause your teeth to become loose or even fall out.

Risk factors for gum disease and periodontitis

Factors that can increase your risk of developing gum disease and periodontitis include:

  • smoking
  • diabetes (a long-term condition caused by too much glucose in the blood)
  • having a weakened immune system (the body's defence system), for example due to a condition such as HIV and AIDS, or chemotherapy (a treatment for cancer)

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) is a severe form of gum disease caused by bacteria that are usually present in the mouth. As with other types of gum disease, ineffective oral hygiene is the main risk factor. Other risk factors include:

  • smoking
  • having a weakened immune system
  • malnutrition, when you do not eat enough of the right food groups to get all the nutrients that you need for good health
  • stress, when there is too much pressure placed on you

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth, and can cause your teeth to become loose and fall out.

Plaque
Plaque is a sticky substance that is made up of bacteria. It can build up on your teeth if you do not brush them.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some are good for you.

Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Page last reviewed: 13/07/2011

See your dentist if you think you have gum disease (gingivitis) or periodontitis.

Your GP can diagnose mild gum disease and give you advice about good oral hygiene. However, for more serious gum disease or periodontitis, you need to see a dentist. They will confirm the diagnosis and recommend any further treatment that is necessary.

Gum disease

Gum disease can usually be diagnosed from your symptoms and will not require any further tests.

Periodontitis

Periodontitis requires a thorough dental examination. Your dentist may examine your mouth using a periodontal probe. This is a medical instrument that is shaped like a thin silver stick, with a bend in one end. 

The periodontal probe is inserted beside your tooth, underneath your gum line. In healthy teeth, the gums should be attached to the teeth and the probe should not be able to slide very far below your gum line. You may have periodontitis if the probe is able to slide deeper under the gum line than normal. 

In some cases, an X-ray may be needed to check the condition of your teeth and jaw bone. An X-ray uses radiation to take images of the bones inside your body, which will highlight any abnormalities in your teeth.

Acute necrotising ulcerative gingivitis (ANUG)

You will be referred to a dentist if you have symptoms of acute necrotising ulcerative gingivitis (ANUG). The dentist will be able to diagnose the condition from your symptoms. It is important that you see your dentist as soon as possible because ANUG can cause serious complications.

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth, and can cause your teeth to become loose and fall out.

Page last reviewed: 13/07/2011

One of the best ways to treat all kinds of gum disease (gingivitis), including periodontitis and acute necrotising ulcerative gingivitis (ANUG), is to practise good oral hygiene.

Gum disease and periodontitis

Good oral hygiene

Good oral hygiene involves:

  • brushing your teeth for 2-3 minutes twice a day (in the morning and last thing at night)
  • using an electric toothbrush if possible (unless you have ANUG, see below)
  • using a toothpaste that contains fluoride if your water supply is low in fluoride (fluoride is a natural mineral that helps to protect against tooth decay)
  • flossing your teeth at least three times a week
  • not smoking
  • seeing your dentist regularly (at least once every one to two years, but more frequently if necessary)

Mouthwash

Antiseptic mouthwashes that contain chlorhexidine or hexetidine are available over-the-counter (OTC) from pharmacies. There is some debate about whether these are necessary for people with healthy gums.

Your dentist may recommend that you use a mouthwash if it helps control the build-up of plaque (the soft, sticky substance that forms when bacteria collect on the surface of your teeth). Your dentist will tell you which type of mouthwash is most suitable and how to use it.

Chlorhexidine mouthwash is not suitable for women who are pregnant or breastfeeding. It can also stain your teeth brown if used regularly. Rinse your mouth thoroughly in between brushing your teeth and using a chlorhexidine mouthwash because some ingredients in toothpaste can prevent the mouthwash from working.  

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) should always be treated by a dentist. However, if you see your GP before visiting a dentist, they may provide you with some treatment while you wait to see your dentist. Possible treatments are described below.

Antibiotics 

Metronidazole or amoxicillin are the most commonly prescribed antibiotics for ANUG. You will usually have to take these antibiotics for three days.

Amoxicillin is not suitable for people who are allergic to penicillin. Amoxicillin can also cause the contraceptive pill to fail, so women taking the contraceptive pill should use an additional form of contraception while taking amoxicillin and for seven days afterwards.

Metronidazole can react with alcohol, causing you to feel very unwell. Therefore, it is a good idea not to drink any alcohol while you are taking metronidazole and for 48 hours afterwards.

Metronidazole and amoxicillin may also cause the following side effects:

  • nausea (feeling sick)
  • vomiting
  • diarrhoea

Painkillers

Paracetamol and ibuprofen are the most commonly prescribed painkillers. They are also available over-the-counter (OTC). They may help reduce the pain and discomfort that is caused by your ulcers.

Paractemol and ibuprofen are not suitable for everyone, so read the manufacturer's instructions before taking them. Aspirin should not be given to children who are under 16 years of age.

Mouthwash

A mouthwash that contains chlorhexidine or hydrogen peroxide may be prescribed. Some chlorhexidine mouthwashes are also available OTC, although they may not be as effective as a hydrogen peroxide mouthwash.

Always read the instructions before using mouthwash because some types may need to be diluted in water before they are taken. They are usually used two or three times a day.

Chlorhexidine mouthwash is not suitable for women who are pregnant or breastfeeding. It can also stain your teeth brown if used regularly. Rinse your mouth well between brushing your teeth and using a chlorhexidine mouthwash because some ingredients in toothpaste can prevent the mouthwash from working.  

Good oral hygiene

As with gum disease and periodontitis, if you have ANUG, continue to practise good oral hygiene as described above. However, because ANUG can cause painful ulcers, brush your teeth with a very soft toothbrush and avoid using an electric brush.

Dental treatments

If your GP refers you to a dentist, they may recommend the following treatments:

  • scale and polish
  • root planing
  • antibiotics
  • surgery

These are described in more detail below and can be used for gum disease, periodontitis and ANUG.

Scale and polish

To remove plaque and tartar (hardened plaque) that can build up on your teeth, your dentist may suggest that you have your teeth scaled and polished. A scale and polish is a type of 'professional clean' that is usually carried out at your dental surgery by a dental hygienist.

A scale and polish involves having the plaque and tartar scraped away from your teeth with a special instrument, before your teeth are polished to remove any marks or stains. If a lot of plaque or tartar has built up on your teeth, you may need to have more than one scale and polish. 

Root planing

In some cases of gum disease or periodontitis, root planing may be required. Root planing is a cleaning procedure to clean bacteria from the roots of your teeth. Before having the treatment, you may need to have an anaesthetic (painkilling medication) to numb the area. You may feel some pain for up to 48 hours after having root planing.

Further treatment 

If you have severe gum disease, periodontitis or ANUG, you may need further treatment, such as surgery, to remove the affected tooth. Your dentist can tell you about the procedure that is required and how it is carried out.

If you are having surgery or root planing, you may be given antibiotics (medication to treat infections). Your dentist will tell you whether these are necessary.

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth and can cause your teeth to become loose and fall out.

Plaque
Plaque is a sticky substance that is made up of bacteria. It can build up on your teeth if you do not brush them.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some are good for you.

Ulcers
An ulcer is a sore break in the skin or on the inside lining of the body.

Stopping smoking

Smoking is the most significant risk factor that you can influence for gum disease and periodontitis. Giving up smoking can greatly improve your oral hygiene.

If you decide to stop smoking, your GP will be able to refer you to a local smoking cessation service which will provide you with dedicated help and advice about the best ways for you to give up smoking. You can also call the National Smokers Quitline at 1850201203, or log on to www.quit.ie, or join our facebook page at www.facebook.com/hsequit for further support.

Page last reviewed: 13/07/2011

If you develop gum disease (gingivitis) and do not have the plaque or tartar (hardened plaque) removed from your teeth, your condition may get worse and lead to periodontitis.

If you have periodontitis and do not receive treatment, you may develop a series of further complications. These can include:

  • recurrent gum abscesses (painful collections of pus)
  • increasing damage to the periodontal ligament (the tissue that connects the tooth to the socket)
  • increasing damage to the alveolar bone (the bone in the jaw that contains the sockets of the teeth)
  • receding gums
  • loose teeth
  • loss of teeth

Acute necrotising ulcerative gingivitis (ANUG)

If acute necrotising ulcerative gingivitis (ANUG) is not treated, it can cause more severe complications. The infection can spread to all areas of your gums and the alveolar bone surrounding your teeth. This can lead to:

  • the gums between your teeth being completely destroyed
  • large ulcers (open sores) leaving permanent holes in your gums
  • loose and unstable teeth

If ANUG is not properly treated the first time you have it, you are more likely to have recurring cases in the future. This can leave you with:

  • bad breath (halitosis)
  • bleeding gums
  • receding gums

Gangrene

In very rare cases, ANUG can lead to a condition called gangrene. Gangrene occurs when tissue starts to die and waste away. The type of gangrene that can occur as a result of ANUG is known as noma.

Noma affects the lips and cheeks. If you develop noma, you may have to have the dead tissue removed. Noma usually only affects people who:

  • have a very weak immune system (the body's defence system), for example those with conditions such as HIV and AIDS
  • are malnourished and do not eat enough of the right food groups to get all the nutrients that they need for good health
     

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth and can cause your teeth to become loose and fall out.

Plaque
Plaque is a sticky substance that is made up of bacteria. It can build up on your teeth if you do not brush them.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some are good for you.

Ulcers
An ulcer is a sore break in the skin or on the inside lining of the body.

Page last reviewed: 13/07/2011

Good oral hygiene

The best way to protect your gums from gum disease (gingivitis), periodontitis and acute necrotising ulcerative gingivitis (ANUG) is to always practise good oral hygiene. This means brushing your teeth twice a day and flossing at least three times a week. For more information about good oral hygiene, go to Treatment of gum disease.

Visiting the dentist

If you have never had gum disease and have good oral health, you may only need to visit your dentist every one to two years for a check-up. It is very important that you attend your dental appointments so that any problems with your teeth and gums can be detected and treated early.

If you have had problems with gum disease or periodontitis in the past, you may need to visit your dentist more frequently. At each dental appointment, your dentist will discuss with you when you need to return for your next appointment.

If you are more at risk of developing problems with your gums, for example if you smoke or have diabetes (a long-term condition caused by too much glucose in the blood), you may be advised to visit your dentist more frequently. This is so that your teeth and gums can be closely monitored.

Glossary

Gum disease (gingivitis)
Inflammation of the gums, normally due to a build-up of dental plaque.

Periodontitis 
This is when the inflammation of the gums also affects the bone surrounding the tooth and can cause your teeth to become loose and fall out.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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