Gingivitis and periodontitis

Gingivitis (often referred to as 'gum disease') is a condition which causes your gums to become red, inflamed and swollen. It can also cause your gums to bleed when you brush your teeth.

Gingivitis is normally caused by a build up of plaque on the teeth. Plaque is a sticky substance made up of bacteria, which is usually removed when you brush your teeth. However, if plaque is left to build up on your teeth, the bacteria will start to release toxins which can irritate your gums, making them painful.

Who gets gingivitis?

Most people experience a mild case of gingivitis during their lifetime. However, it is important to make sure that you look after your teeth and gums, and that any case of gingivitis is sufficiently treated. A mild case of gingivitis can usually be treated simply by practising a good oral hygiene routine, such as brushing your teeth twice a day,(in the morning and last thing at night) and flossing daily (or at least three times a week). However, if left untreated, gingivitis can develop into other forms of gum disease which can cause more serious complications.

Periodontitis

Periodontitis (which used to be called pyorrhoea when severe) is another condition which affects your gums, and often follows a case of gingivitis. It can make your teeth feel loose and, in some cases, it can make your teeth fall out. This is because the inflammation that starts in your gums, spreads, and affects the tissue and bone that help keep your teeth secured in place.

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 rare and usually only affects those with a weakened immune system, or those who are malnourished. It causes ulcers to develop on your gums which are intensely painful. The ulcers develop after the gums become infected with bacteria. As well as the ulcers, ANUG causes the gums to swell, making it very difficult to eat and drink. It can also cause the tissue around the gums to fall away, so that your teeth become loose.

A healthy set of gums should be pink and firm, and will keep your teeth securely anchored into place. Your gums should not bleed when your touch or brush them. If you develop gingivitis, it is your gums that will primarily be affected.

The main symptoms of gingivitis include:

• tender, painful gums,
• swelling and redness in the gums, and
• bleeding gums, after you brush your teeth.

If you go on to develop periodontitis, the pain, bleeding and swelling of your gums may intensify. You may also experience other symptoms, including:

• bad breath (halitosis),
• a foul taste in your mouth,
• difficulty eating,
• pus coming from the gums,
• teeth becoming loose,
• teeth falling out, and
• abscesses (collection of infected fluid) on your gums.

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) is a rare condition, but the symptoms tend to be more severe than those associated with gingivitis and periodontitis. Symptoms of ANUG can include:

• fever,
• feeling generally unwell,
• intensely painful, bleeding gums,
• severe bad breath (halitosis),
• difficulty swallowing, or talking,
• excessive amount of saliva in your mouth,
• metallic taste in your mouth, and
• ulcers on your gums, in between your teeth.

Gingivitis and periodontitis can be caused by a variety of factors, but the most common factor is a build up of plaque.

What is plaque?

Plaque is a soft, sticky substance which is made when bacteria collects on the surface of your teeth. It can be easily removed by brushing your teeth (twice a day) and flossing (daily).

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 your dentist, or dental hygienist, using a procedure known as 'scaling', or 'scale and polish'. During a scaling procedure, the tartar will be scraped from your teeth using a special instrument. Your teeth can then be polished (if necessary) to remove any marks, or stains.

When plaque and tartar build up near the gums, the bacteria can cause the gums to become sore and inflamed, which is what causes you to develop gingivitis. If your gingivitis is not treated, and the plaque and tartar build up further, you may go on to develop periodontitis, which can cause your teeth to become loose, and even fall out.

Oral hygiene

Gingivitis and periodontitis are often caused by poor oral hygiene. This is because poor oral hygiene usually leads to a build up of plaque and tartar on your teeth, which in turn causes your gums to become infected and inflamed. To ensure that bacteria does not build up in your mouth, you should brush your teeth twice a day, and floss them regularly. If you fail to keep your teeth and mouth clean, then you put yourself at risk of developing gingivitis and periodontitis.

Risk factors

There are a number of factors which can increase your risk of developing gingivitis and periodontitis. These include:

• smoking,
• diabetes, and
• having a weakened immune system (as a result of AIDS, HIV, chemotherapy treatment, or other conditions which suppress your immune system)

Acute necrotizing ulcerative gingivitis (ANUG)

Risk factors for acute necrotizing ulcerative gingivitis (ANUG) include:

• immunocompromise (where your immune system is weakened, leading to an increased risk of infection),
• malnutrition,
• smoking,
• stress, and
• ineffective oral hygiene.

ANUG is a rare condition, and it is usually prevented by good oral hygiene and prompt treatment of gingivitis and periodontitis.

Gingivitis

Gingivitis can usually be diagnosed from your symptoms alone and, in most cases, you will not require any tests or procedures to confirm your diagnosis. If your GP suspects that you have gingivitis and periodontitis, they will refer you to a specialist.

Periodontitis

Your GP will refer you to a dentist if they suspect that you have periodontitis, because this form of gum disease requires a thorough dental examination. Your dentist may examine your mouth using a periodontal probe to measure the depth of the groove between your gums and your teeth. The probe is inserted beside your tooth and goes underneath your gum line. If the groove is deeper than normal, then this is usually a strong indication that you have periodontitis. In some cases, you may require an X-ray to check the condition of your teeth and jaw bone.

Acute necrotizing ulcerative gingivitis (ANUG)

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

One of the best ways to treat gingivitis and periodontitis is to practice good oral hygiene. You can do this by:

• brushing your teeth twice a day (in the morning and last thing at night),
• flossing daily, and
• not smoking.

If possible, it is best to use an electric toothbrush to clean your teeth. You should also try using fluoride toothpaste if your water supply is low in fluoride. Fluoride is a natural mineral, which helps to strengthen your tooth enamel, protecting it from tooth decay.

As part of your treatment programme, you may also be prescribed an antiseptic mouthwash spray or gel which you will usually have to use for one month. The most commonly prescribed mouthwashes are chlorhexidine and hexetidine. A lot of these antiseptic solutions can be bought over-the-counter (OTC), and your GP or dentist can advise you on which is the best to use.

To make sure that plaque and tartar do not build up on your teeth, you may be advised to visit your dentist, so that your teeth can be 'scaled and polished'. This procedure involves having plaque and tartar scraped away with a special instrument, before being polished to remove blemishes and stains.

Some more severe cases of periodontitis may require a short course of antibiotics to help treat your infected gums. The most commonly prescribed antibiotics include metronidazole and doxycycline. You will normally have to take these antibiotics three times a day, for three days. However, you should not take doxycycline if you are pregnant, or breastfeeding because it may damage your baby's bones. It can also cause the contraceptive pill to fail, so it is important to use an additional form of contraceptive (such as a condom) while you are taking the antibiotic, and for seven days afterwards.

Acute necrotising ulcerative gingivitis (ANUG)

Acute necrotising ulcerative gingivitis (ANUG) should always be treated by a dentist. If you decide to see you GP before visiting your dentist, your GP may provide you with some treatment while you wait to see your dentist. This treatment may include:

• 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. Women taking a contraceptive pill should be aware that amoxicillin can cause contraception to fail. You should therefore use additional contraceptive whilst taking amoxicillin, and for seven days afterwards.
• Analgesics - these medicines are more commonly known as painkillers, and may help to reduce the pain and discomfort caused by your ulcers. Paracetamol, or ibuprofen, are most commonly prescribed. However, ibuprofen is unsuitable for people with asthma. Children who are under 16 years of age should not take aspirin.
• Mouthwash (chlorhexidine or hydrogenperoxide)- these are special types of mouthwash which will help treat your infection. They are usually used two or three times a day.

As with gingivitis and periodontitis, you should continue to practice good oral hygiene. However, because ANUG can cause painful ulcers, you should brush your teeth with a very soft toothbrush, and should avoid using an electric brush. If a soft toothbrush is also too painful, you may want to consider using your finger covered in a soft cloth to clean your teeth. However, you should only clean your teeth in this way if it is too painful to use a conventional toothbrush.

Stopping smoking

Stopping smoking can greatly improve your oral hygiene. If you need help or advice about stopping smoking, you can call the free NHS Smoking helpline on 0800 169 0 169. Advice is available between 7am-11pm seven days a week. Your GP will also be able to advise you about smoking services in your local area.

If you develop gingivitis and fail to have the plaque or tartar removed from your teeth, your condition may worsen and lead to periodontitis. If you go on to develop periodontitis and do not receive treatment, then you may develop a series of further complications, which may include:

• recurrent gum abscesses (collections of infected fluid),
• loose teeth,
• loss of teeth,
• damage to the bone (alveolar) and thin layer of tissue (periodontal membrane) which surrounds the root of the teeth, and
• receding gums.

So, if you develop gingivitis or periodontitis, it is very important that you get the condition treated as soon as possible on order to minimise the risk of developing further conditions, such as periodontitis.

Acute necrotising ulcerative gingivitis (ANUG)

If acute necrotising ulcerative gingivitis (ANUG) is left untreated, it can cause more severe complications. Inadequate treatment of ANUG can cause the infection to spread to affect all areas of your gums, as well as the bones which surround your teeth. The gums found in between your teeth may end up being completely destroyed, leaving your teeth loose and unstable.

If ANUG is not properly treated the first time you get it, it may also mean that you are more likely to have recurring cases of ANUG in the future. This can leave you with frequent bad breath (halitosis) and bleeding gums.

In very rare cases, ANUG can lead to a condition known as gangrene. Gangrene occurs when your tissue starts to die and waste away. The affected skin and tissue usually turn black. You will usually also lose feeling in the affected areas, although the skin surrounding the gangrenous tissue will often be very painful.

The type of gangrene which results from ANUG is known as noma. Noma affects the lips and cheeks. If you develop noma, you may have to have the dead tissue cut away. This often means you will also require some re-constructive plastic surgery to repair the missing tissue. Noma only tends to affect those with a very weak immune system, or people who are malnourished.

Good oral hygiene

The best way to protect your gums from gingivitis, periodontitis and acute necrotising ulcerative gingivitis (ANUG) is to always practice good oral hygiene. This means brushing your teeth twice a day (in the morning and last thing at night), ideally using an electric toothbrush. You should also try to floss daily (or at least three times a week).

Visiting the dentist

If you have never had gingivitis, and you have good oral health, you may only be required to visit your dentist once every two years for a check up. It is very important that you attend your dental appointments (particularly if you only have one very two years), so that any problems with your gums and teeth can be detected and treated efficiently and promptly. If you have had problems with gingivitis or periodontitis in the past, then you may have to visit your dentist more regularly (at least once a year). Your dentist will discuss with you an appropriate time for your next appointment.

If you are more at risk of developing problems with your gums (for example, you smoke, are diabetic or have a weakened immune system) then you may be advised to visit your dentist more frequently so that your teeth and gums can be more closely monitored. If you suffer from a build up of plaque or tartar, your teeth may need to be scaled, or scaled and polished (see 'treatment' section) every few months. Reducing plaque and tartar build up may also help reduce the risk of gingivitis.