Periodontitis: the gum disease that destroys bone without hurting

What gum disease covers, and what periodontitis destroys

The periodontium is the set of four tissues that support a tooth. The gum forms the visible part and seals the neck of the tooth. Cementum covers the root. The periodontal ligament links that cementum to the bone through fibres held under tension, which makes each tooth a slightly suspended structure rather than a fixed one. The alveolar bone houses the root and remodels continuously.

A tooth is therefore not driven into the jaw like a nail. It is attached, and that attachment is exactly what periodontitis consumes. The international classification agreed in 2017 defines the disease by interdental clinical attachment loss measurable at two or more non-adjacent teeth, together with bone loss visible on a radiograph (Papapanou et al., 2018).

The same classification also defines periodontal health for the first time, on an intact periodontium and on a reduced one, which matters for anyone who has already been treated: a mouth that has lost bone can return to a stable, inflammation-free state without that bone coming back (Chapple et al., 2018).

Gingivitis and periodontitis: where the line falls

Both conditions share the same cause and the same first signs, which is why they are so often confused. The distinction is nonetheless sharp, and it governs everything that follows.

Gingivitis is inflammation confined to the gum. The ligament and the bone are untouched, the attachment is intact, and the original state returns once the plaque is removed. The case definition adopted in 2017 rests on a measurable threshold, bleeding on probing: a patient with an intact periodontium is classed as a gingivitis case above 10% of bleeding sites, and as generalised above 30% (Trombelli et al., 2018).

Periodontitis begins when that inflammation crosses the line and reaches the attachment. From that point the gum can be settled, the inflammation extinguished and the disease held stable, but the bone that has gone does not grow back on its own. Periodontitis is described in the literature as an irreversible inflammatory condition, which makes gingivitis the only stage at which a complete cure remains available (Chapple et al., 2015).

Gingivitis	Periodontitis
Inflammation of the gum only	Ligament and bone affected
Attachment intact	Interdental attachment lost
Reversible within weeks	Bone loss does not reverse
Bleeding when brushing	Bleeding, pockets, loose teeth
Brushing and a scale suffice	Needs periodontal care

Not every case of gingivitis turns into periodontitis, and nothing about that progression is automatic. It depends on how long the inflammation is left in place and on individual susceptibility, which smoking, diabetes and inherited factors weigh on heavily.

The warning signs, and when to see a dentist

None of these signs is diagnostic on its own, and several can coexist without the person concerned thinking much of them. Their value lies in marking active inflammation, the only situation in which acting early changes the outcome.

What you notice	What it points to
Bleeding when you brush	Active gum inflammation
Red, swollen, sore gums	Gingivitis under way
Persistent bad breath	Bacteria deep in a pocket
A tooth looking longer	Recession and attachment loss
A new gap between teeth	Interdental bone loss
Food trapping where it never did	Contact points have shifted
A tooth that moves or drifts	Bone support badly reduced
Pus at the gum margin	A periodontal abscess

NHS guidance separates two levels of urgency, and the distinction is a useful one. Book an ordinary appointment if your gums bleed when you brush or floss, if they are swollen and sore, or if bad breath persists despite good cleaning. Ask for an urgent appointment if your gums are severely painful or swollen, if teeth are loosening or falling out, or if ulcers or lumps appear in your mouth (NHS, 2026). Outside surgery hours, your practice answerphone or NHS 111 will direct you.

Bleeding on its own already deserves an appointment, because it sits at the only stage that is still fully reversible. A loose tooth or an abscess should not wait for your next routine check-up.

Why periodontitis so rarely hurts

The absence of pain is the most misleading feature of this disease, and the main reason patients present late. Deep decay hurts because it approaches the pulp, a densely innervated tissue. Periodontitis destroys supporting structures whose slow breakdown produces no comparable signal.

Pace matters as much as anatomy. Bone loss is measured in fractions of a millimetre a year and the gum adapts as it goes, so teeth look gradually longer and spaces gradually open without any single day marking a change. Bleeding on brushing, the one reliable early sign, is almost always read as a delicate gum rather than as established inflammation.

Pain does eventually arrive, late, and for a reason other than the disease itself. It usually accompanies an abscess, which the international classification defines as an acute lesion with pus accumulating in the gingival wall of a pocket (Papapanou et al., 2018). A tooth that has become mobile enough to interfere with chewing is likewise reporting a loss of support that is already considerable.

What raises your risk

Plaque is the necessary condition for the disease, but it does not explain its severity. Two people with comparable cleaning habits do not develop comparable damage, and thirty years of research have identified what makes the difference.

Smoking, and now vaping

The most robust review on the subject pooled twenty-eight prospective longitudinal studies and concluded that smoking increases the risk of periodontitis by 85%, with a combined adjusted risk ratio of 1.85 (Leite et al., 2018). Tobacco impairs the local immune response and the blood supply to the gum. It also produces a treacherous side effect: by reducing bleeding, it hides the very sign patients rely on, so a smoker’s disease is typically found later and further advanced.

Vaping is a newer question, and the evidence remains thin. A narrative review in the British Dental Journal reports that some studies find worse periodontal health and a poorer response to periodontal treatment among e-cigarette users than among non-smokers, while the evidence base overall is mixed and short of high-quality work. Current research suggests vaping is less damaging to the periodontium than conventional smoking, and the guidance from the British Society of Periodontology and Implant Dentistry is that patients should be told plainly how little is known (Robson et al., 2025).

Diabetes, in both directions

Diabetes is a major risk factor for periodontitis, and susceptibility is increased by approximately threefold in people who have it, with a clear relationship between the degree of hyperglycaemia and the severity of the gum disease (Preshaw et al., 2012). The relationship runs the other way as well: periodontal inflammation makes glycaemic control harder, and treating the gums is associated with a reduction in HbA1c of roughly 0.4%.

The consequences reach beyond the mouth. In the same review, macroalbuminuria and end-stage renal disease were twice and three times more frequent respectively among people with diabetes who also had severe periodontitis, compared with those who did not. That is a reason to treat the two conditions in parallel rather than one after the other.

Inherited susceptibility

Family history comes up constantly in what patients tell their dentist, sometimes as a reason to give up in advance. The systematic review that pooled data from more than fifty thousand people put the heritability of periodontitis at 0.38 in twin studies, while genome-wide association studies detected far less, at 0.07 for combined disease definitions, rising with severity and when the interaction with smoking was taken into account (Nibali et al., 2019).

That gap points to an inherited susceptibility that is real and partial: it makes surveillance more worthwhile without making the disease inevitable.

Age and general health

Prevalence climbs steadily with age, and the international picture gives the scale of it: 42% of American adults aged 30 and over have periodontitis, with 7.8% having the severe form, which is most prevalent among people over 65 and among smokers (Eke et al., 2018). Age itself is not the cause, it simply accumulates years of exposure.

Other circumstances shift individual susceptibility: hormonal change at puberty, in pregnancy and at the menopause, medication that reduces saliva flow, immune deficiencies and nutritional shortfalls. Crowding or an overhanging filling does not cause the disease either, but both create corners a brush reaches badly, where plaque organises faster.

What protects your gums

Preventing periodontitis and controlling gingivitis are the same task, since the second always precedes the first. The European working group on primary prevention takes daily mechanical plaque control as the foundation and stresses that interdental cleaning delivers a benefit brushing alone cannot reach, because bristles do not enter the spaces between teeth (Chapple et al., 2015).

In practice this comes down to three habits. Brushing twice a day with a fluoride toothpaste, taken slowly along the gum margin rather than only across the visible faces. Cleaning between the teeth every day, with interdental brushes where the spaces allow and floss where they do not. Regular examinations, at an interval matched to your own risk rather than to a fixed calendar. NHS advice adds one detail worth keeping: do not rinse with mouthwash straight after brushing, as it washes away the concentrated fluoride you have just applied (NHS, 2026).

Diet works on gum health indirectly. Free sugars and sweet fizzy drinks feed the biofilm and raise acidity in the mouth, which drives decay and sustains an environment where plaque thrives. Cutting how often you consume them matters more than cutting how much, since every separate exposure restarts the cycle. Stopping smoking remains the single measure with the best-documented effect on how the disease behaves.

How a dentist diagnoses periodontitis

A diagnosis does not rest on how the gum looks, since the surface can appear close to normal above a deep lesion. It rests on measurement, taken with a graduated periodontal probe slid gently between tooth and gum at six points around each tooth.

In UK practice this begins with the basic periodontal examination, the screening score recorded sextant by sextant at a routine appointment. The British Society of Periodontology’s implementation group built its diagnostic pathway for the 2017 classification around that established screening step, so that a screening score leads on to full pocket charting where one is warranted (Dietrich et al., 2019).

Charting produces two figures per site. Probing depth in millimetres, which sits between 1 and 3 mm around a healthy tooth and indicates a pocket beyond 4 mm. Bleeding on probing, which says whether the inflammation is active at the time of the examination. Combined with the position of the gum margin, these give the true attachment loss.

Radiographs complete the clinical picture by showing the bone itself. Periapical or panoramic films reveal how much bone height remains along each root, which no visual examination can supply, and they are the only way to see lesions sitting at the root tip.

Staging, grading and what your diagnosis means

Since 2017 periodontitis is no longer split into chronic and aggressive forms. It is described by a stage, expressing severity and complexity at the time of diagnosis, and by a grade, expressing how fast it has been progressing (Tonetti et al., 2018). The stage is read from the worst-affected tooth, as bone loss expressed against root length.

Stage	Bone loss on the worst tooth
Stage I	Under 15% of the root
Stage II	Coronal third of the root
Stage III	Middle third of the root
Stage IV	Apical third of the root

The grade divides that percentage of bone loss by the patient’s age, which separates damage accumulated slowly over decades from rapid damage in someone young. The stage thresholds above and the grade thresholds below are those adopted for UK practice by the British Society of Periodontology (Dietrich et al., 2019).

Grade	Bone loss divided by age
Grade A	Ratio below 0.5
Grade B	Ratio between 0.5 and 1
Grade C	Ratio above 1

A case is called localised when fewer than 30% of teeth are involved and generalised beyond that. UK primary care guidance adds a third label describing where you currently stand: a case is stable with bleeding on probing under 10% and probing depths of 4 mm or less, in remission when depths are controlled but bleeding remains above 10%, and unstable at depths of 5 mm or more (SDCEP, 2026). That wording is what allows a treated patient to be told the disease is being held rather than cured.

This classification determines the approach taken, the number of appointments and the recall interval, which our article on periodontal disease treatment sets out in full. The most advanced situations, where keeping the teeth is no longer a given, are covered in our guide to severe periodontal disease.

Other forms worth knowing about

Apical periodontitis, which starts inside the tooth

The word periodontitis in fact covers two distinct diseases. The one described so far starts at the gum margin and travels down the root. Apical periodontitis starts from the inside: untreated decay reaches the pulp, infection follows the root canal, and an inflammatory lesion forms at the root tip where it meets the bone.

Its frequency is striking and largely unrecognised. The largest meta-analysis on the subject, covering 114 studies and nearly 35,000 people, found the lesion in 39% of root-filled teeth against 3% of teeth that had never been treated, and in roughly half of adults at the individual level (Tibúrcio-Machado et al., 2021). Because it is visible only on a radiograph, the authors consider even that figure an underestimate.

The chronic form progresses silently for years. The acute form announces itself with severe continuous pain that often leads to an emergency appointment, and which is, for many patients, the first perceptible sign of an infection that has been present for a long time.

Periodontitis in younger patients

The old label of juvenile or aggressive periodontitis was removed from the classification in 2017 in favour of description by stage and grade (Papapanou et al., 2018). The clinical reality it described has not gone anywhere. In a teenager or young adult, the disease can advance quickly with a marked preference for the first molars and the incisors, producing bone loss out of all proportion to the visible plaque and without dramatic gum inflammation.

These cases now sit at grade C, the rapid-progression band, and they justify screening the rest of the family. A case in a sibling or a parent makes a periodontal examination worth arranging for the others before any bone loss becomes visible.

Crowded teeth, braces and gum health

Crowding and malocclusion do not trigger periodontitis by themselves. Their effect is mechanical: they create recesses a brush cleans poorly, where plaque settles and calculus forms faster. It is the inflammation sustained by that deposit, not the misalignment, that destroys the attachment.

The same reasoning applies to the appliance itself. Brackets, wires and ligatures multiply the surfaces plaque can hold on to, which is why gingivitis is so common among teenagers in fixed braces. Tooth movement carried out on an inflamed periodontium worsens attachment loss, while the same movement on controlled inflammation does not. The order of operations therefore matters more than the choice of technique.

With an appliance in place, interdental cleaning stops being an optional extra and becomes the decisive part of daily hygiene, with a brush sized to each individual space. Where teeth have drifted under the effect of periodontitis, repositioning them is considered once the disease is stable, and belongs among the situations described in our guide to restoring your teeth.

What gum disease means for the rest of your body

The links between periodontitis and general health have generated a large literature, and it repays reading with the precision the authors themselves use. The consensus report from the European Federation of Periodontology and the World Heart Federation concludes that there are independent associations between severe periodontitis and cardiovascular disease, and describes the inflammatory mechanisms that make them plausible (Sanz et al., 2020). An established association is not a demonstrated cause, and the consensus says so in those terms.

Diabetes stands on firmer ground, because the relationship has been shown to run in both directions and because periodontal treatment moves a measurable clinical marker (Preshaw et al., 2012). It remains the best-documented connection between looking after your gums and a parameter of general health.

When periodontitis has already cost you teeth

Untreated periodontitis ends in the loss of the worst-affected teeth, and that loss raises a question of rebuilding. Alveolar bone exists only to house roots, so it resorbs wherever a tooth has gone, steadily reducing the volume available for a future implant.

Two principles govern this stage. The first concerns sequence: the disease has to be stable before anything is rebuilt, or the same inflammatory process establishes itself around the new fixtures. The second concerns support: where bone height or width no longer suffices, a dental bone graft precedes placement, and marked recession may call for gum grafting to restore an adequate band of attached gum. The replacement options themselves are set out in our dental implant guide.

Treating periodontitis with Body Expert in Turkey

Extensive periodontal work sits outside what most patients expect to pay, and the bill rises sharply once teeth have to be replaced as well. That is why a growing number of patients look abroad for the reconstruction stage, and why the quality of the organisation around the treatment matters as much as the treatment itself.

Body Expert arranges these visits at its partner clinic in Istanbul, selected for its facilities and for the experience of its surgeons, with savings of up to 70% against UK private fees. The arrangement covers your nights in a 5-star hotel with breakfast, VIP transfers between airport, hotel and clinic, a dedicated English-speaking patient coordinator throughout your stay, and 12 months of post-operative follow-up. Flights are not included and remain your own cost.

The process starts when you send recent photographs and radiographs. A free quote reaches you within 24 hours, with no commitment, based on an assessment of your periodontal situation. A full examination is repeated on arrival, and the initial plan is adjusted if the clinical findings and the radiographs taken in Istanbul call for it.

Frequently asked questions

Does periodontitis hurt?
In the great majority of cases it does not, which is precisely what makes it hard to catch. Pain arrives with a periodontal abscess, or when a tooth becomes mobile enough to interfere with eating, so at an already advanced stage. Bleeding on brushing remains the earliest and most reliable signal.

Can periodontitis be cured?
The disease can be stabilised but not erased: lost bone and lost attachment do not return, which is why the literature describes it as an irreversible condition (Chapple et al., 2015). Once inflammation is controlled, a case can stay stable for years, provided supportive care continues.

Is gum disease contagious?
The disease itself does not transfer, although the bacteria involved do circulate in saliva within a household. That transfer is not enough to start periodontitis in someone with healthy gums and adequate cleaning, since individual susceptibility and persistent plaque remain the deciding factors.

At what age should I start worrying about it?
Prevalence rises markedly from the fourth decade onwards, but rapid forms do occur in teenagers and young adults. Persistent bleeding justifies an appointment at any age.

Will a scale and polish sort it out?
A scale removes calculus above the gum line and deals effectively with gingivitis. It does not reach the base of periodontal pockets, where the bacteria driving bone loss are concentrated, which is why established periodontitis calls for a specific course of care.

Should I see a periodontist rather than my usual dentist?
Screening and routine cases belong with your general dental practitioner, who records the basic periodontal examination and takes the radiographs. Severe cases, rapidly progressing disease and surgical situations are the ones where a referral to a specialist in periodontology is worth asking about.

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