Periodontics (Gum Treatment)

Gum disease is not one condition but two distinct stages, and the difference between them is the most important thing for a patient to understand.

Gingivitis is inflammation of the gum. It is the tissue's response to bacterial plaque on the tooth surface: redness, swelling and bleeding when brushing. At this stage the bone is not yet involved and the condition is fully reversible. Remove the plaque consistently and the gum returns to health.

Periodontitis is different. Here the inflammation has passed beyond the gum into the ligament and the bone that hold the tooth in the jaw. Deepening pockets form between tooth and gum, the bone recedes, and in advanced stages teeth become mobile. Bone that has been lost does not come back.

We stress this distinction because when "gum inflammation" is used for both, a patient can mistake serious bone loss for a simple bleeding problem. The two differ in treatment and in urgency.

In adults, the most common cause of tooth loss is not decay but advanced gum disease. The reason it progresses quietly is simple: in most cases it does not hurt.

When gum disease does cost a tooth, treating that gap is affected by the same ground. In an area with reduced bone support, planning an implant may require grafting; with a bridge, the soundness of the supporting teeth becomes decisive. Gum treatment therefore affects not only the teeth you have but everything that might be done later.

Gum disease does have signs — but most of them are things patients treat as normal.

• Bleeding when brushing. The most common sign and the most misinterpreted. Healthy gums do not bleed when brushed. If they bleed, the answer is better brushing rather than less.
• Redness and swelling. Healthy gum is pale pink and firm.
• Bad breath. The source can be bacteria in the pockets — though not all bad breath is gum-related; digestive and ENT causes exist too.
• Receding gums. Teeth look longer, roots become exposed and sensitivity begins.
• New spaces between teeth. A visible sign of lost support.
• A change in how the bite feels, or mobility. An advanced finding.
• Discharge or a blister on the gum. A pocket infection draining itself.

The main reason it is missed is the absence of pain. Decay hurts and brings people in; periodontitis progresses silently for years and patients often arrive only when teeth start to move. By then most of the lost bone cannot be recovered.

The second reason is that bleeding gets normalised. "My gums are just sensitive, they always bleed" describes a disease rather than a personal characteristic.

So diagnosis rests on measurement: each tooth is probed at six points to record pocket depth, bleeding is charted, and bone level is assessed radiographically. Saying "your gums are fine" without those measurements is a guess.

Gum disease is caused by bacterial plaque, but the same amount of plaque does not produce the same outcome in everyone. Risk factors make the difference, and two of them are far stronger than the rest.

Smoking. The strongest modifiable risk factor. It harms in two directions: it accelerates the progression of the disease and it reduces the response to treatment. It also has an insidious effect — nicotine constricts vessels, so bleeding decreases in smokers. The most visible warning sign is suppressed, and the patient believes things are improving.

Diabetes. Uncontrolled diabetes delays healing and impairs the response to infection. The relationship runs both ways: advanced gum disease also makes blood glucose harder to control. In diabetic patients, periodontal treatment matters for general health as much as for the mouth.

Other factors: genetic susceptibility, stress, certain medications (those causing dry mouth, some blood-pressure and epilepsy drugs), hormonal changes in pregnancy, and inadequate oral hygiene.

We ask about these at the consultation and build the plan around them. Telling a smoker this can be uncomfortable — not telling them is worse, because the outcome of the treatment depends on it.

1. Charting. Each tooth is probed at six points, bleeding is recorded and bone level assessed radiographically. That is the map treatment starts from, and the same measurements are repeated at the end to compare.
2. Scaling and root surface debridement. Deposits above and below the gum are removed and the root surface smoothed. In deep pockets this is done quadrant by quadrant under local anaesthetic.
3. Oral hygiene instruction. This step is not decoration; it is half the treatment. Brushing technique and interdental cleaning are practised together.
4. Re-evaluation. Measurements are repeated after roughly six to eight weeks. Most pockets close at this stage.
5. Surgery where needed. For pockets that remain deep at re-evaluation, surgical options are considered.
6. Maintenance. Continued with recall every three to four months.

You generally do not feel pain during scaling; deeper debridement and surgery are carried out under local anaesthetic. Tenderness for a few days afterwards is ordinary.

After treatment you may notice the gums have receded slightly. That is not a side effect but a sign of healing: as swollen, inflamed tissue resolves, the true level becomes visible. Teeth can look slightly longer and there may be temporary sensitivity.

Surgical options include pocket-reduction procedures and, in selected cases, regenerative techniques. Regeneration can genuinely gain bone, but not in every case: the shape of the bone defect has to suit it. The general rule holds — not all lost bone comes back, and the aim is to stop the loss.

Recession means exposure of the root surface, and it has two consequences: appearance and sensitivity.

Knowing the causes accurately matters, because the myths are widespread. The real causes are plaque and inflammation, aggressive or incorrect brushing, a thin gingival biotype, teeth positioned outside the bone envelope, and previous periodontal disease.

The crown material is not a cause. When the gum recedes around a metal-backed crown a dark line appears, but the recession itself does not come from the metal. Using a zirconia crown prevents that line; it does not prevent recession.

An exposed root surface is not covered by enamel; it is softer and decays more readily. So recession is a decay-risk issue as much as an aesthetic one.

Treatment depends on the situation: desensitising agents and fluoride for sensitivity, composite coverage for limited recession, and root coverage surgery in suitable cases. Coverage surgery usually needs a connective tissue graft from the palate, which means a few days of discomfort at the donor site — and that should be said in advance.

The most effective approach is removing the cause: correcting brushing technique stops the progression in most cases.

Gum treatment comes before aesthetic work in the plan, and that order does not change on request. There are three concrete reasons.

First, the foundation is moving. Inflamed gum is swollen. When the inflammation resolves the tissue settles to its true level. A veneer margin placed against the swollen position becomes visible months later — and it cannot be corrected without remaking the ceramic.

Second, the future of the teeth is uncertain. Crowning a tooth with advanced bone loss is investing in a foundation of unknown lifespan. Which teeth can be kept has to be established first.

Third, with implants the risk is direct. Implants placed into active gum disease carry a markedly higher risk of peri-implantitis. The tissue around an implant responds to the same bacteria in the same way.

So a patient arriving for smile design gets a periodontal assessment first. For some that means the plan lengthens by a few months — and saying so can cost us the case. We say it anyway, because the alternative is losing the result.

Setting expectations correctly is part of the treatment. What periodontal therapy can and cannot do is clear.

The fourth row is the important one. That lost bone does not return sounds like bad news, but the real message is this: a patient who comes early loses far less. The difference between treatment started when bleeding was noticed and treatment started when teeth began to move is not recoverable.

How long results last depends entirely on maintenance. For a patient who has had periodontal treatment, the standard six-monthly check is not enough; a three to four-month interval is needed. That is to catch recurrence early, and neglecting it loses everything gained within a few years.

Like every treatment carried out here, periodontal therapy carries a lifetime guarantee on materials and workmanship. One point stated plainly: our guarantee covers the work we do; recurrence of the disease depends on daily hygiene, smoking and general health, which are outside our control and which no clinic can guarantee. We write that at the outset.

What decides the outcome of periodontal treatment is not what happens in the clinic but what happens at home afterwards. That is not an exaggeration: the appointment removes the deposits, but plaque begins to reform within twenty-four hours.

• Brush twice daily — with a soft brush, at forty-five degrees to the gum margin, without pressure. Brushing hard does not clean; it causes recession.
• Clean between the teeth daily — floss or interdental brushes. Gum disease begins between the teeth, where a brush does not reach. This is the most skipped and most important item on the list.
• The right interdental brush size — each space needs a different size; we work out together which ones you need.
• Antiseptic mouthwash — only when prescribed and only for the period prescribed. Long-term chlorhexidine stains the teeth; it is not a product for continuous use.
• Stopping smoking — the single step that most changes the outcome.
• Recall every three to four months — the standard six-month interval is not enough for a periodontal patient.

A recall appointment is not only a clean; the measurements are repeated and compared with the original chart. That is how recurrence is spotted while the patient still feels nothing.

For patients travelling from another city or country, maintenance runs where you live. After treatment you are given your charts, your radiographs and a summary of what was done; handing those to your own dentist keeps the follow-up unbroken. Do not forget to ask for them — in periodontal treatment, follow-up matters as much as treatment.

The mouth is not a separate compartment. In advanced gum disease the total surface area of the pockets corresponds to a wound roughly the size of a palm, and that surface is continuously inflamed. The relationship between that inflammation and the rest of the body is a researched question.

The strength of the evidence varies by topic and is worth reporting without overstatement. The strongest data concern diabetes: the relationship runs both ways, and measurable improvement in glycaemic control has been shown after periodontal treatment. In diabetic patients, gum treatment should be seen as part of diabetes management.

The link with cardiovascular disease has been shown consistently, but it is an association; gum disease has not been proven to cause heart disease. Shared risk factors — smoking, age, diabetes — may explain part of it. A source that speaks with certainty here is claiming more than the evidence supports.

In pregnancy, hormonal changes heighten the gingival response and pregnancy gingivitis is common. Oral hygiene and regular check-ups matter during that period. Scaling and urgent treatment can be carried out in pregnancy; elective cosmetic work is postponed.

Associations have also been reported with respiratory disease and rheumatoid arthritis, where the evidence is more limited.

The practical conclusion: gum treatment is a health matter rather than a cosmetic one. Your general health and your medications are asked about at the consultation — that is part of the plan rather than a formality.

The gum is not only a health matter; it frames the smile. Where teeth look short the problem is not always their length — sometimes it is the gum level, and telling the two apart prevents an unnecessary veneer case.

A gummy smile. Excess gum showing when smiling. There is more than one possible cause: teeth covered too far by gum, an upper lip that lifts a long way, or the vertical position of the jaw. Any intervention chosen without identifying the cause misses the result; where the cause is the lip, cutting gum is not the answer.

An uneven gum line. Where the gum margins of the teeth are not level, the smile looks unbalanced. Limited corrections can be made by reshaping the gum.

Healing time is critical here and it is the most skipped point. After soft-tissue reshaping, at least six weeks should be allowed for the tissue to settle, and three months or more where bone was recontoured. Without that the gum recedes afterwards and the margin of the restoration becomes visible. It is the most common error in smile design planning.

Where the overgrowth is inflammatory, no surgery is needed. If the gum is swollen from inflammation, the correct treatment is to resolve the inflammation rather than to cut. In most cases the appearance after the tissue settles is already the result that was wanted.