How to prevent gum problems (or stop gum disease from getting worse)
Why is it important to prevent gum disease?
More teeth are lost because of gum problems than because of tooth decay. Gum disease (also known as periodontal disease) is painless, and most people are unaware that they have it. As it progresses, the bone which anchors the teeth in the jaw is lost, making the teeth loose. If this is not treated, the teeth may eventually fall out or have to be taken out because of pain.
Usually gum disease progresses slowly and can be stopped from getting worse. Some people are genetically predisposed to developing gum disease. This is especially true for aggressive forms of gum disease.
What is gum disease and what causes it?
When you don’t brush your teeth for a while, you will notice a yellowish sticky paste (called plaque) that accumulates on them. This material looks like food debris, but it’s actually a film of bacteria which forms on the surface of the teeth and gums every day.
Many of these bacteria are harmless. But others happily munch away at the same food you’re eating and then excrete toxins and enzymes – using the grooves where your tooth meets the gum as a toilet of sorts. Bacteria thrive in the plaque environment and multiply until they account for nearly 100% of the mass of the plaque. This is why it’s important to remove it.
When your body notices the toxins, it mounts a defense against them by creating lots of new little blood vessels in the area to fight off the infection. The new blood vessels make the gums look red and swollen. The bacteria attack the blood vessels, which then become fragile and bleed easily.
This first stage of gum disease is called gingivitis, and is usually easily reversed by following the tips on this page.
What can I do to prevent gum disease, or to stop it from getting worse?
Your mission is to remove the soft sticky plaque deposit from every surface of every tooth (including just below the gum line). Plaque is very soft and easy to remove. You may have removed it with your nail at some time or other. If it does not come away easily, it is not plaque.
Such a hard deposit is tartar, also known as calculus, and no amount of brushing will remove it. Plaque starts to turn into tartar in as little as two days. A dentist or dental hygienist can remove tartar for you during a dental cleaning. Resist brushing harder, as this can cause toothbrush damage.
So how do you do remove plaque?
There are two elements to cleaning every surface of every tooth:
How to brush your teeth well
Use a toothbrush with a small brush head (to get in hard-to-reach spots), and a pea-sized blob of toothpaste which contains 1350-1500ppm fluoride. It’s best to try to work the paste right into the bristles of the brush so that it doesn’t all fall off in a big lump when you first put it into your mouth.
Ideally, you will want to invest in an electric toothbrush. The ones that come out on top for plaque removal in research studies are rechargable oscillating rotating toothbrushes 1 2 – those in the Oral-B PRO, Smart, or Genius range. Research shows that they work better for almost everyone than manual toothbrushes. Most dentists use these themselves.
You don’t need the top-of-the-range one – the difference in price is usually due to accessories, gimmicks and design. All the Oral-B brushes brushes from the Pro 2000 upwards have the same number of rotations and oscillations, and clean equally well. Of course, they are still more expensive than manual ones (and the replacement brush heads are quite expensive), but there are often special offers both in shops and on Amazon.
Choose one of the small round brush heads, rather than the oblong “Deep Sweep” or “Dual Clean” models.
When brushing, make sure that you take your time and don’t rush – the key is to clean every surface of every tooth. This may take you longer than 2 minutes (many electric toothbrushes have a timer built in, but just ignore the timer if you can’t get the job done properly within that time).
Watch how to brush teeth with an electric toothbrush:
It’s a good idea to choose an order in which you brush your teeth and stick to it. If you always brush in the same order, then you are unlikely to miss some areas while doing others twice.
Here is an example (feel free to do it in whatever order you like though):
- Clean the outer surfaces of your upper teeth, then your lower teeth
- Clean the inner surfaces of your upper teeth, then your lower teeth
- Clean the chewing surfaces of your upper teeth, then your lower teeth
Especially difficult or awkward areas should receive extra attention, as should those areas more prone to problems. These are different for different individuals – ask your dentist or hygienist.
At the end, gently brush your tongue to remove bacteria and freshen breath.
Spit out the remaining toothpaste and don’t rinse, so that you get the full benefit of the fluoride for preventing tooth decay.
Brushing with a manual toothbrush:
If you prefer to use a manual toothbrush (or if you need one for your travels), choose a soft one with a small brush head. The small brush head will ensure that you can access all areas of your teeth, and the soft bristles will help prevent toothbrush abrasion. Plaque is a soft substance, and you don’t need to scrub hard to remove it.
- Brush at a 45 degree angle to your teeth (a slightly upward motion if you are brushing your top teeth and a slightly downward motion for your bottom teeth). Brush gently and thoroughly by moving the brush back and forth in short, tooth-wide strokes.
- Gently brush the inner surface of your teeth back and forth using short circular motions. Then move to the outer surface and then the chewing surface on top. Pay particular attention to where the tooth meets the gum as this is where plaque builds up.
- Take your time and don’t rush – the key is to clean every surface of every tooth (most people take 2 to 3 minutes).
- At the end, gently brush your tongue to remove bacteria and freshen breath.
- Spit out the remaining toothpaste and don’t rinse, so that you get the full benefit of the fluoride for preventing tooth decay.
How often should I brush, and when?
The general consensus is that you should brush twice a day – ideally first thing in the morning (before breakfast) and before going to bed. If you brush last thing before bedtime, the fluoride has a chance to work undisturbed during the night.
You shouldn’t brush much more often than that to avoid damage to your teeth and gums. You also shouldn’t brush straight after eating, or after drinking acidic drinks (see below for an explanation!).
Why before breakfast? Wouldn’t it be better to wait until afterwards to get rid of bits of food stuck between your teeth?
There are two reasons:
- Plaque builds up quicker as we sleep because we produce less saliva. Even if you brush your teeth before bed, there will be plenty more plaque in the morning. Brushing before breakfast gets rid of the buildup of plaque. This means that the sugars from your food won’t be able to mix with the bacteria from the plaque to form the acid which attacks tooth enamel for at least 20-30 minutes after eating. Also, the fluoride toothpaste will give an extra protective layer against the acid attack.
- The obvious solution – brushing straight after you’ve finished eating – unfortunately isn’t a good idea! Here’s why: eating breakfast, especially one high in sugar and acids, for example orange juice or sugary cereal, can lower the pH level in your mouth which weakens the tooth enamel. If you brush straight after breakfast, you may scrape off the softened or weakened enamel.
Although brushing your teeth before breakfast would be ideal, it doesn’t fit in with everyone’s schedule. Don’t worry too much if it doesn’t suit you – as long as you brush last thing at night and one other time during the day (at least 30 minutes after a meal), you’ll be fine.
If you’re worried about bits of breakfast being stuck between your teeth before heading out, try rinsing with water – this usually dislodges any food particles.
Cleaning between the teeth
The bristles of the toothbrush don’t properly reach between the teeth. There are several ways of cleaning between your teeth, depending on the size of your gaps and what you find easiest, for example:
- Interdental brushes
- Interdental rubber brushes
You may find it impossible to clean between your teeth if you haven’t had a professional cleaning for a while due to fear, because of the build-up of hard deposits (tartar/calculus) between teeth. You will find things much easier once these hard deposits have been removed. Ask your dentist or hygienist which interdental cleaning method they recommend for your teeth!
Interdental brushes (Traditional and Rubber Interdental brushes)
The most effective method for cleaning between teeth is to use interdental brushes wherever the interdental space is big enough 3 4 5. They come in lots of different sizes and you’ll likely need to use a combination of sizes for different-sized spaces in between your teeth. They are colour-coded to make it easier to remember which ones to use where. They also come in different shapes to make it easier to access certain areas of your mouth. Ask your dentist or hygienist which size(s) and type(s) are right for your gaps.
The most popular brand of traditional interdental brush is Tepe (see photo above).
Not everyone is a fan of these brushes. If you find traditional interdental brushes difficult to use, for example because you keep poking the metal bit into your gums or your gaps are too narrow, you may find rubber brushes easier. They look like this:
Don’t use interdental brushes where the spaces in between teeth may be too narrow to safely accommodate them. If you’re unsure, ask your dentist or hygienist for advice!
If you have very narrow spaces between teeth and healthy gums, you may find that neither of the brushes above work for you. In that case, floss is the best option. You may also want to use floss in addition to interdental brushes for those teeth which are too close together to fit the smallest interdental brush.
Flossing has received a bad press in recent years following the release of an Associated Press report in August 2016 under the headline “Medical benefits of flossing unproven”, which looked at research carried out over the last decade. For example, a review of 12 randomized controlled trials 6 found only “very unreliable” evidence that flossing might reduce plaque after one and three months (the review did find though that flossing in addition to toothbrushing reduces gingivitis compared with toothbrushing alone). The European Federation of Periodontology has released guidelines which state that interdental brushes are essential for treating and preventing gum disease, and that floss is of little value unless the spaces between your teeth are too tight for the interdental brushes to fit without hurting or causing harm 7.
However, this does not mean that flossing is “pointless” or “doesn’t work”. It is much more likely that most people don’t floss very effectively (or skip it altogether), or that the research wasn’t very well designed.
If you’ve been successfully flossing up until now, or if you prefer floss to interdental cleaners from an environmental perspective (less plastic waste), don’t give up! Anecdotal evidence certainly suggests that daily flossing has a very positive effect on gum health if done correctly, so the key is to do it right.
How to floss well
- Take about an arm’s length of dental floss and wind most of it around your left middle finger or index finger (the middle finger is recommended, but whichever is easiest for you). Wind the remaining floss around the same finger of the opposite hand. This hand will take up the used floss as you go along. If you’re left-handed, you may want to wrap most of the floss around your right middle finger or index finger instead (it’s easier to use your dominant hand for doing the winding).
- Hold the floss tightly between your thumbs and index fingers.
- Gently slide the floss between two teeth, using a gentle side-to-side motion. Be careful not to snap the floss between teeth.
- When the floss reaches the gum line, pull both ends of the floss in the same direction to form a C shape against one tooth. Pull the floss tightly and gently slide it up and down against one tooth, and especially below the gum line (see the round close-up between pictures 3 and 4 in the illustration above). Repeat this motion a few times so you know that you’ve cleaned the tooth’s surface thoroughly.
- Pull the floss against the other tooth and repeat the motion. Be very gentle and try not to scrape the floss too hard against your gums.
- Repeat this wherever two teeth are touching, and behind the very back teeth. Each time you move on to next space, use a fresh segment of floss and wrap the used one around the finger that starts off with the short end of floss.
- Once you’re finished, throw the floss away.
Some more tips:
- A lot of websites say that it only takes a couple of minutes to floss. This can be disheartening if it takes you a lot longer – and of course, if you have a small mouth, teeth which aren’t perfectly straight, very tight spaces or less-than-stellar dexterity, it almost certainly will take longer. It’s not a race, so take your time. You will probably find that you do get a bit faster as time goes on.
- Have a road-map of what order you’re going to floss your teeth in. For example, you could start in the middle of your lower teeth and work your way back to one side and then repeat this process on the other side. Then do the same thing on the upper teeth. Find a floss order that works for you and stick to it.
- Floss once a day. If this takes too long at first, try alternating lower and upper teeth on alternate days until you get the hang of it.
Which type of floss should I use?
There are many different types of floss available – waxed and unwaxed, thin floss and tape. Our gut feeling is that floss with a more uneven surface works better at trapping plaque. Fluffy expanding floss (e.g. Corsodyl Daily Expanding Floss, Sensodyne Gentle Floss Expanding, or GUM Access Floss) is excellent for cleaning purposes but has a tendency to shred.
To make things easier, many dentists recommend non-shredding floss made of teflon (Colgate Total Pro Gum Health Interdental Floss or Oral-B Pro-Expert Premium Floss in the UK, Oral-B Glide in the US).
Most research appears to show that the type of floss is less important than actually using it. So choose a floss that that works for you! If you don’t get on with one type of floss, try another (and another, until you find one that suits you).
There are also special types of floss for use with implants, bridges, and braces (e.g. Oral-B Superfloss and Oral-B Glide Threader Floss).
The floss keeps shredding and getting stuck!
Ideally, floss should smoothly glide between the teeth. If you’re having problems with floss shredding between certain teeth, let your dentist and/or hygienist know so they can have a look at the problem for you. There can be many reasons, for example the floss might snag on dental tartar that’s built up, and simply removing this tartar will stop the shredding (and make flossing much easier). Or there could be an overhang or leftover cement from previous dental work. Sometimes trimming or buffing the offending edge to make it smoother can solve or at least help with the problem. Or your dentist or hygienist can show you an alternative technique to use in these spots.
Keeping the floss taut when inserting and removing it from each gap, and holding it firmly against the side of a tooth while doing so will keep shredding to a minimum. Having plenty floss makes it easier to keep it wrapped around your fingers and pulled tight.
Some types of floss are specifically designed not to shred: as mentioned above, dental tape or floss made of PTFE (Teflon) tends to break into two if it snags, rather than fray and leave tiny threads behind. In the UK, this is currently being sold as “Colgate Total Pro Gum Health Interdental Floss” and “Oral-B Pro-Expert Premium Floss” (the equivalent in the U.S. is called “Oral-B Glide”).
My gums bleed when using interdental brushes or flossing!
If you haven’t used interdental cleaning methods before, or only infrequently, your gums will probably bleed the first few times. This is because the bacteria which have been allowed to thrive have attacked the blood vessels, which has left them fragile and prone to bleeding. Your gums may also feel tender and sore after interdental cleaning.
The good news is that if you keep using interdental brushes or flossing gently, the bleeding will usually stop within a week or two.
Should I floss and/or use interdental brushes before or after brushing?
It doesn’t really matter. On the one hand, interdental cleaning before brushing removes debris from between teeth and thus may allow the fluoride in your toothpaste to penetrate the spaces better. On the other hand, brushing before interdental cleaning means that your teeth are still covered with fluoride, and the interdental brush or floss then distributes some of the fluoride into the spaces in between teeth.
So either option is fine. Interdental cleaning before brushing does have the advantage that you’re less likely to skip it.
It also doesn’t matter whether you clean between your teeth at night or in the morning (or in the afternoon for that matter).
Ideally, interdental cleaning should be done once a day – but if that feels too much, try and start off with alternating days, or doing the bottom teeth one day and top teeth the next, until it becomes easier. Flossing in particular requires a degree of dexterity that doesn’t come naturally to everyone, but practice makes perfect (eventually!).
What about mouthwash?
Unless your dentist has prescribed you a mouthwash for a specific purpose (such as chlorhexidine gluconate for short-term treatment of gingivitis), there is no need for it. Mouthwash is NOT necessary for maintaining good oral health, and can even be counterproductive: using mouthwash after brushing your teeth will wash away the fluoride from the toothpaste (remember the “spit and don’t rinse” rule).
Professional cleanings (aka scale and polish) play an important role in preventing gum disease 8 9. Most dental professionals would recommend having your teeth cleaned every 6 months (or more often if you have existing gum problems). In the UK, dental hygienists can provide these services directly, without the need to go through a dentist for a referral. So you can pick anyone you like – they don’t have to work at the same practice as your dentist.
What else can I do to keep my gums in good shape?
If you currently use tobacco products (cigarettes or smokeless tobacco such as snus), then cutting down or better yet quitting is a great way of improving gum health. Smoking causes people to have more dental plaque. It also causes gum disease to get worse more quickly, because smoking causes a lack of oxygen in the bloodstream, so the infected gums don’t heal.
How to quit smoking
While a lot of people do manage to quit cold turkey, many others struggle with this approach. After all, it takes a while to become a fully fledged 20 a day smoker, so it shouldn’t be surprising that breaking the habit of a lifetime won’t happen overnight.
Traditional nicotine replacement products tend to be pretty vile. Luckily, in recent years e-cigarettes have really taken off. They have helped many people who thought they lacked willpower to finally quit. There are many different models of e-cigarettes on the market, and even more flavours, especially online but also in vape shops. The e-cigarettes found in pharmacies tend not to be so effective.
The beauty of e-cigarettes is that they allow the quitting process to be broken up into easy, manageable stages.
For example, you can start off with e-liquids containing a fair amount of nicotine and gradually reduce the amount (over weeks or months) until you are able to use nicotine-free liquids. You can then continue using these, and gradually reduce the amount you vape over a period of weeks, or months, or years – whatever suits you.
If you’re finding it difficult to go without a cigarette for more than a few hours, the first week of switching to e-cigarettes will still require some willpower – in that case, you could have the occasional cigarette during the first week or so (cutting down each day until by the end of the week, you have entirely replaced them with your e-cigarette).
For more ideas on quitting smoking, visit Smokefree (NHS).
Scottish Dental Clinical Effectiveness Programme SDCEP (2014). Prevention and Treatment of Periodontal Diseases in Primary Care – Dental Clinical Guidance (PDF, 116 pages)
- Robinson P, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny AM, Shaw BC. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews 2005, Issue 2
- Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, Shaw WC. Different powered toothbrushes for plaque control and gingival health. Cochrane Database of Systematic Reviews 2010, Issue 12
- Slot DE, Dörfer CE, Van der Weijden GA. The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. International Journal of Dental Hygiene. 2008;6(4):253-264.
- Imai PY, X.; MacDonald, D. Comparison of interdental brush to dental floss for reduction of clinical parameters of periodontal disease: A systematic review. Canadian Journal of Dental Hygiene. 2012;46(1):63-78
- Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P. Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2013, Issue 12
- Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2011, Issue 12.
- European Federation of Periodontology (2014). Guidelines for effective prevention of periodontal diseases.
- Needleman I, Suvan J, Moles DR, Pimlott J. A systematic review of professional mechanical plaque removal for prevention of periodontal diseases. Journal of Clinical Periodontology. 2005;32 (Suppl 6):229-282.
- Worthington HV, Clarkson JE, Bryan G, Beirne PV. Routine scale and polish for periodontal health in adults. Cochrane Database of Systematic Reviews 2013, Issue 11