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For Your Information

What is Periodontal Disease?

Periodontal disease is an infection of the gums and/or bone that surrounds the tooth. Generally the disease is painless, and most patients are not aware they have a problem until examined by a dentist.

With a healthy tooth, the root is set in the jawbone with a strong ligament, which keeps the tooth tightly attached to the bone. Gum covers the bone, and like skin, protects it from bacteria that are constantly present in the mouth. The gum connects to the neck of the tooth with a band of fibers, which insert just above the bone into the root. In a healthy situation, the gum edge is higher than the fiber attachment, forming a space around the tooth. This is similar to having a turtleneck sweater, and this sulcus should be 2-3 millimeters in depth.


Healthy tooth and gums


Healthy gums

Close up



Probe next to sulcus

Probing 3mm into healthy sulcus


Everyone has bacteria in their saliva continuously. These bacteria precipitate (collect) on all surfaces, forming colorless, sticky colonies called plaque. Unfortunately, this plaque also forms in the space underneath the edge of the gum. If the plaque is not removed (something that takes careful brushing and flossing), it will start to cause an infection in the gum. Plaque that remains on the tooth for a long period of time absorbs salts from the saliva, and becomes hard. This calculus, or tartar, cannot be removed by brushing and flossing, and must be dislodged by a dental professional.




The Stages of Periodontal Disease
The first stage of periodontal disease is gum inflammation, or gingivitis (from "gingiva", meaning gum, and "itis", meaning inflammation). The body reacts to the bacteria by bringing in blood vessels, which carry cells to destroy the bacteria. This makes the tissue appear red, perhaps swollen, and patients may notice bleeding when cleaning their teeth.


Gingivitis starting


Plaque causing inflamed
gums and gingivitis

Gingivitis with calculus
seen between teeth



At this stage there has been no bone destruction, and careful removal of all calculus, along with meticulous patient brushing and flossing, generally completely corrects the problem.

If the gingivitis is not corrected, the bacteria may destroy the fiber barrier, and start moving down the tooth surface. There is a war between the advancing bacteria, and the body trying to defend against invasion. Some of the destruction is caused by the body itself, when attempts to destroy the bacteria also destroy healthy tissue in the area. There are many factors that influence how well your body defends against the bacterial invasion.

As the bacteria advances down the tooth, the inside lining of the gum, and the bone, are destroyed. This penetration of bacteria forms a periodontal pocket, or deepened space between the gum and tooth. By measuring the depth of the space with a periodontal probe your dentist can see how much bone loss has occurred.


Periodontal pocket with bone loss occurring


Periodontal probe measuring pocket


Periodontal probe ready
to measure pocket

Probe inserted 5mm under
gum to base of pocket


Probe held beside gum
to visualize depth of pocket


And when bone is lost, the tooth support is weakened. The tooth will become loose and, if the disease continues, will be lost.


Advanced Periodontitis


Probe next to deep pocket with inflammation seen at the gum margin

Probe inserted 8mm into pocket, indicating severe bone loss

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Gum Recession

In health, there are two types of gum tissues that surround the tooth. The part that is around the neck of the tooth is firmly attached to the tooth and underlying bone, and is called attached gingiva. The attached gingiva is immovable and tough, and deflects food as it hits the gum. Below the attached gingiva is looser gum, or alveolar mucosa. This tissue contains muscle, and is flexible to allow movement of the cheeks and lips. The muscles in the alveolar mucosa are constantly contracting, which pulls on the bottom edge of the attached gingiva. However, normally the attached gingiva is wide and strong enough to act as a barrier, which prevents the gum from being pulled down (receding).


Adequate attached (hard) gum to prevent
spontaneous recession. No grafting needed


Some people are born without sufficient attached gingiva to prevent the muscle in the alveolar mucosa from pulling the gum down. In these cases the gum slowly continues to recede over time, even though the patient may be very conscientious with their oral health. This is not an infection, as is seen with periodontal disease, but rather simply an anatomic condition. Unfortunately, bone recession is occurring at the same time the gum is receding. This is because the bone, which is just under the gum, will not allow itself to become exposed to the oral cavity and moves down with the gum.


Insufficient attached gum
results in recession starting

Insufficient attached gum
without treatment results in
continued loss of gum and bone





Lack of attached gum with resulting recession

Note gum pulling away when cheek muscle retracted. The bone that previously covered the root has also receded.



A lack of attached gingiva is sometimes associated with a high frenum attachment, which exaggerates the pull on the gum margin. A frenum is a naturally occurring muscle attachment, normally seen between the front teeth (either upper or lower). It is normal to have a frenum, but it should not pull on the gum margin or recession will occur. If pulling is seen, the frenum is surgically released from the gum with a frenectomy. Often a new band of hard gum is also added to re-establish an adequate amount of attached gingiva


Child with naturally occurring
high frenum attachment


High frenum with lack of attached gum causing muscle pull and tooth separation

After frenum removal, and
addition of adequate attached gingiva


With the wear and tear of time, even normal attached gum can be worn away, generally from vigorous brushing. This often happens in people with naturally thin tissues, or when the tissues have been stretched during orthodontics. If there is still adequate attached gum to act as a barrier to the muscle, the treatment for recession is to ensure further damage isn't done when brushing. However, if the attached gum is worn to the point where it cannot resist the constant pull of the mucosa, recession will continue unless a new hard band of gum is placed. Unchecked, the recession can cause tooth loss as the bone recedes with the tissue and tooth support weakens.


Recession associated with a lack of attached gingiva. The bone has also receded. Untreated, this may result in tooth loss.

After placement of a gum graft, adequate attached gingiva to prevent further bone/tissue loss.


Recession with no attached gum. Without treatment, the recession will continue. The root is difficult to clean, leading to plaque formation and inflammation.

After placement of new
attached gum.


The replacement of missing attached gum is called gingival grafting. The muscle that is pulling down on the edge of the gum is first surgically resected and repositioned away from the gum margin. Then a small piece of attached gingiva is taken from the roof of the mouth, just adjacent to the back teeth, and transplanted to the site in question. The new tissue reattaches and reforms a new layer of attached gum, which should last a lifetime with proper care. The roof of the mouth heals quickly, just like a skinned knee might. With this procedure the root is not covered, and the tissue stays at the same level as before, except with attached gingiva at the margin. These procedures are very easy on the patient, and rarely require more than over-the-counter pain pills post-operatively (ibuprofen). The most difficult part of the surgery is not chewing on the area for 2 weeks. 

Routine gum grafts ("free gingival grafts") do not cover up the exposed root surface - if this is desired, a different technique is used. Covering the root does not make the tooth stronger, for the bone, which actually holds the tooth in place, does not change regardless of the new gum level. Rather, root coverage procedures are primarily done for cosmetic reasons, or when there is exceptional root sensitivity after recession.



Recession with a lack of attached gingiva.

Gum graft placed, resulting in adequate attached gingiva and health. The root is not covered.


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Last modified: Sunday March 29, 2009