IntroductionIf you were bleeding from a cut, you would act immediately to assess the damage and treat the injury. Bleeding isn’t normal - it’s a cry for help. Nonetheless, many people still think that it’s normal for their gums to bleed when they are brushing or flossing. Bleeding gums are an indication that your gums have been infected with bacteria, which can spread below the gum line and affect surrounding bone and tissue, leading to periodontal disease. This is usually caused by poor oral hygiene.If periodontal disease is detected in its early stage, it is possible to prevent and reverse any damage. However, if it is left untreated and unaddressed, periodontal disease can eventually lead to gum recession, bone loss, and total edentulism (toothlessness). Use this guide to learn about periodontal disease and identify the stages of the disease to determine the proper treatment. Part 1: What is Periodontal Disease?Periodontal disease is a common type of gum infection that can eventually destroy the jawbone and cause tooth loss. The word "periodontal" consists of the words perio, meaning around, and dontal, which refers to teeth. "Periodontal" refers to the structure around the teeth, such as the tissue, bone, and ligaments. Periodontal disease is caused by plaque buildup on your teeth, which can then spread below the gum line. When the disease spreads, it damages the gums and tissue holding teeth in place.Below we will explore the different stages of periodontal disease. Treating the disease in the early stage, and quickly, is critical. Periodontal Disease Pathology Gum disease is largely thought to be caused by the actions of tiny bacteria. This is true across the board from mild gingivitis to severe periodontitis. Typically, periodontal disease begins as harmless biofilm, or bacterial buildup, along the gumline of a person’s teeth. Over time, this biofilm buildup leads to hardened calculus and tartar which, in turn, accelerates the buildup of other harmful types of bacteria. Eventually, the toxins released by these bacteria damage gum tissues, resulting in gum recessions and full-blown periodontal disease. Part 2: Stages of Periodontal DiseasePeriodontal disease is a progressive affliction that gets worse over time. As a result, the signs and symptoms of early-stage periodontal disease may look different than the effects of late-stage periodontal disease. In order to better understand how gum disease works and advances, it is important to understand how periodontal disease staging is defined according to the American Academy of Periodontology (AAP). It is also important to understand what forms periodontal disease may take. Stage 1: Initial PeriodontitisThe first stage is commonly referred to as gingivitis.Signs of gingivitis include redness and swelling of the gums.Gums that bleed while brushing or flossing can also be an important early indication of gingivitis.Catching periodontal disease in its early form is crucial. Early treatment consisting of improved oral hygiene habits and professional care can help prevent further deterioration and even reverse damage.At this stage, untreated periodontitis can still affect the jawbone and surrounding tissue and lead to separation of the gums and teeth. Stage 2: Moderate PeriodontitisThis Moderate Periodontitis stage includes the following symptoms: Damage to supporting gums Teeth in the form of gum recession Seperated gums Loose teeth Bad breath Possibly signs of pusPockets formed from loose gingival tissues can form and deepen over time making them very difficult to clean. Bacteria that gather in these pockets further accelerate damage to gum tissues and bone. This can cause the disease to progress rapidly and without warning.At this stage, professional therapies performed by a periodontist are necessary to remove bacteria and to monitor symptoms to stop the disease from progressing. Stage 3: Severe Periodontitis - with potential for additional tooth lossAt this stage, much of the damage to the gums and teeth is permanent and cannot be reversed.Teeth increase their sensitivity to heat or cold which leads to pain when eating hot or cold foods.Extensive damage to soft tissues and the bone tissues that support the teeth may eventually lead to tooth loss.To prevent the disease from spreading, a periodontist may need to remove rotted teeth and infected tissues. Stage 4: Severe Periodontitis - with potential for loss of the dentitionOnce a patient reaches stage 4, the chances of retaining or salvaging their natural teeth are quite slim. As a result of severe receding gums, remaining teeth are unsupported. Fibers, bone, and ligaments that support the teeth and anchor them in place are completely destroyed, which can result in widespread tooth loss. Part 3: Forms of Periodontitis (Types of Gum Disease)Gum disease can refer to multiple types of infections of the gums, tissue, and underlying periodontal bone tissues.Each person’s case of periodontitis can vary in the severity of the disease.Besides staging, another essential way to categorize the different types of periodontitis is what form it takes. Recognized forms include:1Standard Periodontitis (which is described by staging)2Necrotizing Periodontitis3Periodontitis - as a result of systemic diseases 1. Standard PeriodontitisAs described above, standard periodontitis is typically represented by its stages. In general, each stage is based on the severity and complexity of the management required to treat the disease. 2. Necrotizing PeriodontitisNecrotizing periodontitis is a unique form of gingivitis that spreads quickly and leads to rapid tissue death, or necrotization, in the mouth.Below are three generally recognized types of necrotizing periodontitis. Necrotizing gingivitisThis form of the disease affects only the gums, with patients suffering from bleeding gums, pain, and bad breath. Necrotizing periodontitisThis is indicated by receding gums firmly attached to the teeth. Other symptoms include severe pain, spontaneous bleeding, loss of bone, or exposed bone. Necrotizing stomatitisStomatitis refers to sores in the mouth. This is an aggressive form of gum disease resulting in mucosal and bone loss to the gums and tissue that surround the teeth. Other symptoms include frequent bleeding, severe pain, multiple affected teeth, and gaps between teeth. 3. Standard PeriodontitisPeriodontal disease does not operate in a vacuum. While it is often initiated by bacteria infection and exacerbated by an overabundance of bacteria, many cases of periodontal disease can be tied to other underlying systemic health issues. According to Nature, periodontal disease is associated with several other systemic diseases, including respiratory disease, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome, and cancer.This new understanding of how oral diseases, such as periodontitis, may be linked to other chronic diseases, has changed the way periodontists and doctors view periodontal disease.As a result, doctors now categorize cases of periodontitis that arise from an existing condition in a separate group.Understanding the underlying health causes driving or exacerbating periodontal disease can help periodontists come up with a holistic therapy that addresses not only the symptoms of periodontitis but the root causes as well. Part 4: What Do Healthy Gums Look Like?Healthy gums are firm and pink.Furthermore, gums that are in good shape do not bleed at all with routine brushing and flossing.To keep or obtain healthy gums, it is essential to implement good oral hygiene in your daily life.Regularly brush your teeth, gently, and ensure all parts and surfaces are clean. Also, make sure to brush along your gum line. The American Dental Association recommends brushing for a full two minutes twice a day. How to keep your gums healthyFlossingFlossing helps to keep gums healthy by reaching the in-between places that brushing misses. It leaves bacteria with no place to hide.Each tooth has five surfaces, and it’s important to remember that flossing reaches two of those areas. It strengthens your gums and prevents plaque buildup.Use MouthwashUse a mouthwash to reduce the risk of gum disease and improve your overall oral health. Mouthwash removes food particles, kills harmful bacteria, strengthens tooth enamel, and helps control plaque and gingivitis. This is an additional protection that can be added to your oral hygiene routine.DietYou’ll also want to eat a well-balanced diet that incorporates fruits, vegetables, and lean proteins into your meals. Avoid sugar and starches, which cause tooth decay and bacterial growth.Drink water instead of sugary drinks.Regular Dental ExamsFinally, try to schedule regular dental exams every six months to a year.Professional cleanings remove bacteria and plaque from your teeth and gums, which can prevent gingivitis and slow periodontitis.Plaque and bacterial buildup along your gums can lead to a gum infection, which can lead to periodontal disease.Dental checkups are critical in spotting early signs of gum disease and preventing any existing damage from getting worse. Part 5: Gingivitis: Symptoms and CausesThe beginning stage, and mildest form of gum disease, is known as gingivitis. In this early stage, periodontal disease can still sneak up on you since many people with gingivitis experience only mild discomfort. It may be tempting to ignore gingivitis at this early stage, but over time, it will cost you in money, time, and pain.Detecting and treating gum disease early is vital since gingivitis can be reversed with treatment.However, when gingivitis is left untreated, it can progress into periodontitis. Advanced periodontal disease in the form of periodontitis is characterized by permanent damage such as tooth loss and bone loss. By the time you are diagnosed with periodontitis, it's too late to turn back the clock.Our mouths are teeming with bacterial organisms. This is totally normal as long as the various inhabitants of your mouth are kept in check through proper oral hygiene. An increase in pathogenic (harmful) bacteria can disrupt that balance and cause periodontal disease. How can you tell if your oral microflora is getting out of control? The telltale sign is the presence of plaque.Pathogenic microbes combine with dead cells, mucus, saliva, and other particles to form plaque on our teeth. If the plaque is not removed, it calcifies or hardens and forms tartar. Tartar is so tough that it cannot be removed by simply brushing or flossing at home. The tartar acts as a shield allowing bacteria to colonize, irritate, and damage your gums. Because of the unhealthy population of harmful bacteria in your mouth, your body reacts by sending the immune system into overdrive. This immune response to persistent irritation causes inflammation, which damages gum tissues over time, leading to gum disease.How can you tell if you have gingivitis? The following symptoms signal inflammation in your gums as your body naturally responds to the harmful bacteria: Swollen or/and puffy gums Red gums Gums that bleed easily Bad breath Receding gums Tender gumsIt is not often you get a second chance to avoid an oral health disaster. Dealing with your gingivitis is a crucial preventative step that will help you avoid a lot more pain down the line. Treating gingivitis can be as simple as getting a professional cleaning and following a rigorous daily oral hygiene routine. Patients with chronic gingivitis should check in with their periodontist regularly to ensure their condition is monitored by a professional. Causes of GingivititisInadequate oral hygiene is the most common cause of gingivitis.The buildup of bacterial plaque along and below the gumline can trigger the inflammatory response that leads to gingivitis.If left untreated, gingivitis can progress into a more serious form of gum disease known as periodontitis. Part 6: Periodontitis: Symptoms and CausesBy the time a patient is diagnosed with periodontitis, bacteria has already spread below the gum line. Bacterial toxins may have also caused a separation between the gums and teeth, forming pockets or spaces that trap debris. Over time, these pockets deepen as a combination of bacterial toxins and inflammation weaken then destroy surrounding tissues such as ligaments, bone, and gingival tissues. With the loss of these crucial oral structures, your teeth will loosen and start to fall out.At this advanced stage, the damage caused by periodontitis is irreversible. Even worse, unchecked periodontitis threatens more than just your oral health. New research links periodontitis and other chronic conditions and diseases, including Alzheimer's, cancer, heart disease, and more.Periodontitis does not appear overnight. For most people, it is a gradual progression that takes place over many years. The following are some changes you may experience as gingivitis advances to periodontitis: Chronic bleeding from the gums Pus between your teeth and gums Loose teeth or tooth loss Painful chewing Receding gums or longer appearing teeth Chronic bad breath Chronic sensitive teeth Changes to your natural biteEarly detection and treatment of periodontitis is important. Unfortunately, many individuals do not realize they have advanced gum disease until serious damage has already occurred. One of the best ways to detect periodontitis is to pay regular visits to your dentist or periodontist. Causes of PeriodontitisInadequate oral hygiene, typically over a long period of time, is the most common cause of periodontal disease.Like gingivitis, the ultimate causes of periodontitis revolve around bacteria and inflammation.As discussed in the previous section Gingivitis: Symptoms and Causes, bacteria on the gums and beneath the gum line trigger a destructive immune response in the form of chronic inflammation. In the beginning, this chronic inflammation is typically only mildly irritating. This phase of the development of gum disease is known as gingivitis.Over time, gingivitis progresses into periodontitis. At this stage, the bacteria and subsequent inflammatory response have caused significant and irreversible damage to your gums and underlying bone tissues.Anyone can be susceptible to gum disease, but several factors increase the risk of developing periodontitis. Understanding these risk factors is just as crucial as establishing good oral hygiene habits.Some factors include the following: Older age Smoking or chewing tobacco Hormonal fluctuations expecially during pregnancy People with underlying medical conditions such as diabetes or cancer Genetics Using medications that cause dry mouth Stress Part 7: What Do Healthy Gums Look Like?The first sign of gum disease is the inflammation of gums. So what are healthy gums supposed to look like? Here's a healthy gums checklist for comparison. Healthy gums should be firm and light to a medium pink (or a darker pink depending on your skin pigmentation). Healthy gums do not bleed easily. Sometimes it is easy to miss bleeding if it doesn't make it to the sink. If there's a metallic taste after brushing, it could be a sign of bleeding gums. Healthy gums fit snugly and naturally around your teeth. Healthy gums should not include receding gums or pockets between the tooth and the gum line. Longer than usual looking teeth can be an indication of receding gums. Pay attention to your breath in addition to the appearance of gums. Even though bad breath is normal, regularly rancid breath could be another telltale sign of gum disease. The buildup of bacteria produces foul-smelling gases that can signal gum disease. Part 8: How is Periodontal Disease Treated?Because of the prevalence of periodontal disease and its possible links to other chronic diseases, patients diagnosed with periodontal disease should see a periodontist.Periodontists are dentists specializing in the prevention, diagnosis, and treatment of gum disease as well as the placement of dental implants.Periodontists go through extensive training, including at least three additional years of education beyond dental school, and are experts in treating periodontal disease. Seeing a periodontist instead of a general dentist drastically increases your chances of receiving the best-qualified treatment for periodontal disease.Depending on the severity and the patient's preferences, patients will likely have to undergo periodontal therapy. This can include surgical and non-surgical treatments and techniques. However, overall treatment doesn't end with a visit to a periodontist. Successful treatments should be accompanied by careful daily oral care at home. Surgical TreatmentsIf your periodontitis is severe, dental surgery may be required. Surgical therapies include: 1. Pocket reduction surgery (flap surgery)This involves folding back the gum tissue so that infectious bacteria can be removed with effective deep-cleaning. If there is bone loss, the underlying bone can also be accessed for contouring or smoothing before suturing the gum tissue back in place. 2. Bone graftingYou could lose your teeth if there is bone loss as a result of periodontitis. A bone graft uses your own bone tissue, donated bone, or synthetic bone to repair and replace lost bone. Donor bone material is grafted onto an area of thin or missing bone. This grafted tissue serves as scaffolding for the regrowth of new bone. 3. Gum graftingPeriodontitis can destroy your gum tissues causing gum recession. Receding gums exposes your dental roots and negatively affects your appearance as well as your teeth. In order to repair receded gums, a small amount of tissue from the roof of your mouth or from a donor can be grafted to the affected site. Non-Surgical TreatmentsNon-surgical treatments include antibiotics, and deep-cleaning procedures called tooth scaling and root planing.Deep-cleaning removes tartar and plaque from below the gum line.Root planing involves smoothing away roughness on the roots to prevent bacteria from adhering in the future. Oral Care at HomeNone of the treatments can completely eradicate gum disease without proper oral care at home. Periodontal disease can quickly make a comeback if oral care at home is neglected.The following are six ways you can personally prevent all stages of periodontal disease: Brush and least twice a day or ideally after each each meal. Floss daily Rinse with a mouthwash designed to fight tartar and plaque. Quit tobacco. Attend regular dental checkups every six to 12 months. Eat a healthy diet.Oral Health Is Self-Care It may feel like a constant battle against nature and millions of microscopic, harmful microbes. However, now with the right knowledge, you are in control.Whether you aim to prevent periodontal disease or to treat an existing condition, it's time we start treating our daily oral routines and regular dentist visits as self-care instead of errands we dread.