Merck Manual

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James T. Ubertalli

, DMD, Hingham, MA

Reviewed/Revised May 2022 | Modified Sep 2022
Topic Resources
  • Plaque Overview of Tooth Disorders and tartar Overview of Tooth Disorders build up between the teeth and gums and then spread to the bone under the teeth.

  • The gums swell and bleed, the breath smells bad, and teeth become loose.

  • Dentists take x-rays and measure the depth of pockets in the gums to determine how severe periodontitis is.

  • Repeated professional cleanings and sometimes dental surgery and antibiotics are needed.

More severe periodontitis occurs in people who are susceptible to a more serious infection of periodontal tissue (tissue surrounding the teeth) than occurs in simple gum inflammation (gingivitis Gingivitis Gingivitis is a mild form of periodontal disease characterized by inflammation of the gums (gingivae). Gingivitis results most often from inadequate brushing and flossing but may result from... read more Gingivitis ). Many diseases and disorders, including diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Symptoms of diabetes may... read more (especially type 1), Down syndrome Down Syndrome (Trisomy 21) Down syndrome is a chromosome disorder caused by an extra chromosome 21 that results in intellectual disability and physical abnormalities. Down syndrome is caused by an extra chromosome 21... read more Down Syndrome (Trisomy 21) , Crohn disease Crohn Disease Crohn disease is an inflammatory bowel disease where chronic inflammation typically involves the lower part of the small intestine, the large intestine, or both and may affect any part of the... read more Crohn Disease , leukopenia, and AIDS Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and is treated with antiretroviral medications. If untreated, it can cause... read more Human Immunodeficiency Virus (HIV) Infection , can predispose a person to periodontitis. In people with AIDS, periodontitis progresses quickly. Smoking, vitamin C deficiency Vitamin C Deficiency In countries with low rates of food insecurity, vitamin C deficiency can occur from a diet low in vitamin C, but severe deficiency (causing scurvy) is uncommon. Not eating enough fresh fruits... read more (scurvy), and emotional distress also are risk factors for periodontitis.

Periodontitis can affect people of any age, including young children. Some people have severe gingivitis for many years without developing periodontitis. Others may develop periodontitis, especially at early ages (20 to 30 years old), without first having significant gingivitis.

Periodontitis is one of the main causes of tooth loss in adults and is the main cause of tooth loss in older people. Infection destroys the bone that holds the teeth in place. The erosion weakens the attachments and loosens the teeth. An affected tooth may eventually fall out or need to be pulled (extracted).

Causes of Periodontitis

Most periodontitis is the result of inflammation of the gums (gingivitis Gingivitis Gingivitis is a mild form of periodontal disease characterized by inflammation of the gums (gingivae). Gingivitis results most often from inadequate brushing and flossing but may result from... read more Gingivitis ) and a long-term accumulation of plaque (a filmlike substance made up primarily of bacteria, saliva, food debris, and dead cells that is continually being deposited on teeth) and tartar (hardened plaque) on the teeth and the gums. Pockets form between the teeth and gums and extend downward between the root of the tooth and the underlying bone. These pockets collect plaque in an oxygen-poor environment, which promotes, in people with immune system susceptibilities to periodontitis, the growth of aggressive forms of bacteria. The plaque and bacteria cause chronic inflammation that damages the tissue and bone that hold teeth in place. If the disease continues, eventually so much bone is lost that the tooth may become painfully loose and the gums recede Gum Recession Gum recession is the loss of tissue at the gumline with exposure of the root of the tooth. Recession usually occurs in thin, delicate gum tissue or in response to overaggressive toothbrushing... read more Gum Recession . Tooth loss typically starts in a person's 40s.

Did You Know...

  • Periodontitis is the main cause of tooth loss in older people.

Periodontitis: From Plaque to Tooth Loss

Healthy gums and bone hold the tooth firmly in place.

Periodontitis: From Plaque to Tooth Loss

Plaque buildup irritates the gums, and they become inflamed (gingivitis Gingivitis Gingivitis is a mild form of periodontal disease characterized by inflammation of the gums (gingivae). Gingivitis results most often from inadequate brushing and flossing but may result from... read more Gingivitis ). In time, the gums pull away from the tooth, creating a pocket that fills with more plaque.

Periodontitis: From Plaque to Tooth Loss

The pockets get deeper, and the plaque hardens into tartar. More plaque accumulates on top.

Periodontitis: From Plaque to Tooth Loss

Bacterial infection moves down to the root of the tooth and eventually destroys the bone supporting the tooth. Without this support, the tooth loosens and falls out or requires extraction because of a periodontal abscess.

Periodontitis: From Plaque to Tooth Loss

The rate at which periodontitis develops differs considerably, even among people with similar amounts of tartar. Such differences occur because each person's plaque contains different types and numbers of bacteria and because periodontitis results from the person's unique immune system response to bacteria in the plaque. Periodontitis may cause bursts of destructive activity that lasts for months followed by periods when the disease apparently causes no further damage.

Symptoms of Periodontitis

The early symptoms of periodontitis are tender, swollen, bleeding, and red gums and bad breath (halitosis Bad Breath Bad breath is a frequent or persistent unpleasant odor to the breath. Certain diseases produce substances that are detectable on the breath, but these odors are typically mild and not considered... read more ). As more and more bone is lost, the teeth loosen and shift position, and chewing becomes painful. Frequently, the front teeth tilt outward. Periodontitis usually does not cause pain unless an infection forms a collection of pus (abscess) in a pocket, the teeth loosen enough to move while chewing, or the periodontitis affects a person having human immunodeficiency virus infection.

Diagnosis of Periodontitis

  • A dentist's evaluation

  • Sometimes x-rays

To diagnose periodontitis, dentists inspect the teeth and measure the depth of the pockets in the gums with a thin probe. X-rays are taken to see how much bone has been lost.

Treatment of Periodontitis

  • Treatment of risk factors

  • Professional cleanings

  • Sometimes surgery and tooth removal

  • Sometimes antibiotics

People who have risk factors, such as poor oral hygiene, diabetes, and smoking, should receive treatment for these risk factors. Treatment of risk factors increases the success of the dentist's treatments of periodontitis.

Unlike gingivitis, which usually disappears with good oral hygiene (daily brushing and flossing), periodontitis requires repeat professional care. People who have good oral hygiene can clean only 2 to 3 millimeters (less than 1/8 inch) below the gum line. However, dentists can clean pockets up to 6 to 7 millimeters (¼ inch) deep using scaling and root-planing techniques, which thoroughly remove plaque and tartar and the diseased root surface.

For pockets 5 millimeters (about 3/16 inch) deep or more, surgery is often required. Dentists or periodontists may access the tooth below the gumline by surgically opening a flap of gum tissue (periodontal flap surgery). They thoroughly clean the teeth and correct bone defects (sometimes by bone grafting) under the flap and then sew the flap back in place. Dentists or periodontists may also remove part of the infected and separated gum (a gingivectomy) so that the rest of the gum can reattach tightly to the teeth and people can then remove the plaque at home. Sometimes teeth are removed (extracted). If the mouth is sore after surgery, a chlorhexidine mouth rinse used for 1 minute twice a day may be temporarily substituted for brushing and flossing.

Dentists may prescribe antibiotics (such as amoxicillin or metronidazole), especially if a collection of pus (abscess Dental Abscess An abscess is a collection of pus. Pus is a mix of white blood cells, dead tissue, and bacteria. It builds up wherever your body is fighting an infection. A dental abscess is an abscess that... read more ) has developed. Dentists may also insert materials (filaments or gels) that contain antibiotics into deep gum pockets, so that high concentrations of the drug can reach the diseased area. Periodontal abscesses cause a burst of bone destruction, but immediate treatment with surgery and antibiotics may allow much of the damaged bone to quickly grow back.

More Information

The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Mouth Healthy: This general resource provides information on oral health, including nutrition and guidance on selecting products that carry the American Dental Association's seal of approval. There is also advice on finding a dentist and how and when to see one.

  • National Institute of Dental and Craniofacial Research: This government site covers a wide variety of topics related to oral and dental health (in English and Spanish), including definitions of common terms and the latest information on clinical trials related to oral and dental diseases.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Betasept, Chlorostat, DYNA-HEX, Hibiclens, Oro Clense , Peridex, Periogard, PerioRx , Perisol
Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox
Flagyl, Flagyl ER, Flagyl RTU, LIKMEZ, MetroCream, MetroGel, MetroGel Vaginal, MetroLotion, Noritate, NUVESSA, Nydamax, Rosadan, Rozex, Vandazole, Vitazol
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