Symptoms and signs of the different stages of the gingivae

In a healthy situation the gums are in close contact with the enamel surface presenting a pink colour and no bleeding.

Prevention of gingivitis

Gingivitis is a reversible infectious disease of the gums caused by bacteria. It is mainly due to poor oral hygiene (bacterial plaque accumulation): 

  • contact between the gums and the enamel surface is partly lost,
  • red/bluish colour of the gums,
  • gums bleed easily.

If present, it is mainly a general condition in the mouth. The supporting tissues (periodontal ligament and alveolar bone) are not affected. When proper hygiene is re-established the gums will appear healthy again. 

The best way to prevent gingivitis or periodontitis is by applying a correct oral hygiene by brushing regularly (twice a day) and using interdental cleaning devices (i.e. dental floss, interdental brushes,…). It is as well very important to have periodic check-ups at the dental office by the dentist/periodontist to check regularly on the health of your gums. If necessary, the periodontist/dental hygienist will perform a meticulous hygiene and give appropriate hygiene instructions. Through these regular visits it is as well possible to detect other dental problems such as caries lesions. These visits can be seen as a preventive measure. 

Prevention of periodontitis

Periodontitis is as well an infection of the gums. It is mainly a condition that will be a continuation of an untreated gingivitis. The initial signs are the same as for gingivitis:

  • contact between the gums and the enamel surface is partly lost,
  • red/bluish colour of the gums,
  • gums bleed easily.

The main difference between the two diseases is that periodontitis affects the supporting tissues (periodontal ligament and alveolar bone are lost) around the tooth. Due to this destruction periodontal pockets are formed which can be locally distributed in the mouth.
Other symptoms are:

  • bad taste or bad breath,
  • retraction of the gums,
  • changes in tooth position,
  • thermal sensitivity,
  • pain,
  • mobility of the teeth,
  • periodontal abscess.

Periodontitis, if not treated properly, can lead to loss of the tooth. It is a natural reaction of the body to eliminate the infection present in the mouth.

Treatment of periodontitis

Treatment of periodontitis is aimed at eliminating the bacteria causing the disease and influencing/changing other risk factors as mentioned above (i.e. smoking reduction/cessation). A detailed clinical, periodontal and radiological study is carried out to evaluate the situation at the beginning. 

During the first step of the active periodontal treatment bacteria are eliminated supra- and subgingivally by scaling (curettage) and root planing (smoothening of the root surface) under local anaesthesia. It is carried out by using very fine instruments (power driven or hand instruments) to be able to access the periodontal pockets present. It is mainly carried out in various sessions (2, 3 or 4 sessions) depending on the severity of the disease and during these sessions the patient is instructed carefully how to perform his/her dental hygiene at home using a toothbrush and interdental devices.


After a 2-month period of healing of the gums, a re-evaluation is performed. Again a detailed periodontal study will be carried out and compared to the initial situation. At that time point the patient is integrated in a maintenance program. It is mainly to avoid relapse of periodontal disease and to be able to interfere immediately when necessary. The frequency of maintenance usually ranges between visits every 4 to 6 months depending on the case.

Surgical treatment of periodontitis

Remaining pockets will have to be treated further to obtain a stable situation. This can be done by periodontal surgery. 


Tratamiento quirúrgico de la periodontitisThis surgery is able to correct more specifically the defects produced by periodontitis. It is again to eliminate in the first place bacteria in very deep pockets, but in specific situations it is as well possible to recover the lost bone and periodontal tissues by using regenerative techniques (using bone graft materials, membranes or enamel matrix derivates).

Another surgical procedure is the one known as mucogingival plastic surgery. It corrects the quantity and quality of the gums in sites were soft tissues have been lost and were aesthetics or sensitivity of the roots are a concern (anterior areas). 

After the surgical procedure, there is again a period of healing. Another re-evaluation will be carried out depending on which surgical procedure has been performed.

Microsurgery in periodontology

Microcirugía periodontal

    • Minimally invasive surgery with a better post-operative healing.
    • Profound disinfection using magnification devices and microsurgical instruments.
    • Better visibility and access during the surgical procedure. 
      • Less traumatic and gentle management of the tissues for sensitive techniques (regenerative, implantology).

      Periodontal maintenance program 

      Mantenimiento periodontalDuring every recall visit the periodontist or dental hygienist will check the clinical situation of every tooth, evaluate the oral hygiene and eliminate the bacterial plaque and calculus in an individualized way. If periodontal pockets are present, these will be debrided in the appropriate way and at the end of the visit a remotivation of the oral hygiene of the patient will take place. The frequency of recall visits will be defined by the patient case but it usually ranges between visits every 3 to 6 months. 

      Periodontal disease can be controlled through active therapy and a consequent maintenance program following the active phase of treatment. The periodic recall visits are very important to avoid recurrence of the disease.

      Risk factors

      Smoking is associated with a wide spectrum of disease including stroke, coronary artery disease, gastric ulcers, cancers of the mouth, larynx, oesophagus,… Approximately 50% of regular smokers are killed by their habit. It has been shown in the dental literature that smokers have more periodontal disease compared to non-smokers. Smoking can modify the microflora in the mouth (harbour more microbial species which are associated with periodontitis), the host response (due to a decrease in the vascularity of the tissues important defensive cells are not present in sufficient amounts to act against the periodontal infection) and the healing response (because nicotine and tobacco smoke affect the microvascularity, the fibroblasts and connective tissue matrix, the bone and also the root surface itself, resulting in a poorer response to periodontal therapy).

      Bad breath problems 

      Bad breath (halitosis) is a problem which is often related to the presence of bacteria in the mouth. If this is the case, this problem can be treated by removing the bacteria related to bad breath commonly as the producers of sulphates on a regular basis. In the niches where those bacteria live (tongue).

      Periodontitis and systemic disease

      Just to make it a little bit more visual. If a patient has a moderate periodontitis (pockets of 5-7 mm), the infected surface area in the mouth could be compared with the size of the palm of the hand or even larger. In these pockets bacteria are highly organized. We talk about a biofilm. But some of these bacteria can be disconnected from this organized biofilm (i.e. during mastication) and will be transported from the pocket through the bloodstream to other parts of the body. The body will react against these bacteria in the blood by producing inflammatory products (such as cytokines) which could have effects on distant organs. In this aspect it is necessary to understand which influences periodontitis can have indirectly on our general health.

      • cardiovascular diseases: there is evidence which show increasing links between the presence of chronic infections and cardiovascular diseases. The latter is still the main cause of death in Europe. The most frequent chronic infections in the mouth are caries and periodontal disease. 

      • pre-term birth / low birth weight babies: the known risk factors are young maternal age, drugs, alcohol, tobacco use, maternal stress, genetic background and genitourinary tract infections. 25-50% of pre-term / low birth weight deliveries happen without any known aetiology, but there is increasing evidence that infection may play a significant role. 

      • diabetes mellitus: people with diabetes (especially type II, showing an insulin resistance, how to explain in more normal words ) are more prone to infection due to a diminished leukocyte function. Those patients have problems with their blood circulation and their collagen metabolism which both play an important role in healing processes. A change in the dental microflora (due to dry mouth problems) especially when their diabetes status is poorly controlled, is another major problem in controlling periodontal disease. When periodontitis is present in a poorly controlled diabetes patient, it may increase the difficulty in controlling glycaemia. But by treating the periodontal disease it may improve the situation of the diabetic patient, even reducing the need for insulin.