Gum disease is the inflammation of the gum and bone supporting the teeth. It occurs due to the accumulation of bacterial plaque and tartar on teeth.¹ Gum diseases can be prevented by adopting good oral hygiene practices and using proper brushing techniques. Several preventive brushing techniques have been introduced for different gum conditions and various age groups.  

What is gum disease?

Gum disease is an infection of the tissues that hold the teeth in place.² This can be a mild infection of the gums(gingivitis) that progresses to the bone and surrounding tissues causing severe gum disease(periodontitis). The gum appears red and swollen with bleeding and loosening of teeth in severe cases.³ According to a CDC report, more than 40% of adults in America have gum disease.⁴ Gum disease presents with minor symptoms initially, but over time it affects adjacent soft tissues and bone that support the teeth(periodontium).³

Types of gum disease

Gum disease can be divided into two categories based on the severity of the disease, and these are gingivitis and periodontitis. Gingivitis is the initial stage of the disease and presents with red and swollen gums with mild pain and bleeding from gums while brushing. When left untreated, gingivitis progresses to a condition called periodontitis, causing gums to pull away from the teeth, severe bleeding, and bone loss.⁵     

Causes of gum disease

• The main factor responsible for gum disease is dental plaque, a thin sticky film that adheres to the teeth; composed of food debris, bacteria, and saliva
• Poor oral hygiene
• Smoking causes gum irritation, reduces blood flow to gums, and weakens immunity against infections⁶
• Hormonal changes during puberty and pregnancy cause increased blood supply to the gum, leading to bleeding from gums⁷
• Metabolic diseases like diabetes reduce saliva flow and increase glucose in your saliva, causing gum disease⁸ 
• Autoimmune diseases like lupus and Crohn’s disease reduce the body's immunity against infections
• Genetics 

Consequences of untreated gum disease 

Untreated gum disease leads to receding gums, bad breath, bleeding from gum, and eventually loss of teeth.⁹ Over time, bacteria may enter the bloodstream and cause serious health conditions like stroke, diabetes, and heart diseases.¹⁰

Preventive brushing techniques

Gum diseases can be prevented by proper brushing of teeth and adopting the right technique for brushing. Several brushing techniques have been developed based on the age and oral condition of the patient.¹¹ These techniques have been found to be quite effective in the removal of plaque.

Fundamentals of preventive brushing

Duration and frequency of brushing

The American Dental Association recommends that people brush their teeth twice a day for about 2 minutes using a toothbrush with soft bristles and fluoride toothpaste. The toothbrush should be placed at a 45-degree angle against the gum to remove debris above and below the gum and make short back-and-forth motions on the outside. The toothbrush should be tilted vertically against the inner surface of the teeth to clean the inside surfaces.¹² You can use a manual or powered toothbrush for brushing. It is advised to replace your brush once every 3 to 4 months.¹³  

How to select the right toothbrush and toothpaste?

Both manual and powered toothbrushes can effectively remove plaque. The American Dental Association recommends using toothbrushes with angled bristles as they are more efficient at plaque removal. It is also suggested to use soft-bristled toothbrushes because it is associated with lower chances of gum abrasion.¹² Powered toothbrushes are more useful in children with braces, elderly people, and people with disabilities who find it difficult to use manual toothbrushes.¹¹

It is advised to use fluoride-containing toothpastes as fluoride helps to prevent tooth decay. It is also important to ensure that the toothpaste has the American Dental Association seal on it, which guarantees that the product meets the recommended standards.¹¹

Some preventive brushing techniques

Various preventive brushing techniques have been introduced for effective plaque removal.¹⁴ Some of these are described below:

Horizontal scrub technique

This technique uses the basic horizontal or back-and-forth motion while brushing teeth. It is commonly used by everyone while brushing.

Fones’ technique

Named after the pedodontist Dr Fones, this technique is suggested for preschool children. Here, small circular motions are made on teeth using small kids' toothbrushes. This technique is easier for children to follow while brushing.

Bass technique

Bass technique is indicated in patients with gum disease. In this method, the brush is placed at a 45-degree angle on the gumline and small vibratory motions are made on the gum while moving the bristles back and forth over the teeth. This helps to remove plaque and debris from the gum pockets and also provides massage to the gingiva. 

Stillman technique

This method is suggested for patients with severe gum disease. Zigzag motion along with sweeping and vibratory motions are used while brushing teeth. The gum-to-tooth sweeping motion removes plaque from the gumline.

Charters technique

Charter’s method is effective for people wearing bridge or artificial teeth, as well as in brace-wearers. It is particularly useful while cleaning the area between the teeth, and is demonstrated by placing the tip of the brush perpendicular to the spaces between the teeth and performing short vibratory motions.

Watanabe’s technique

This technique was introduced by Dr Watanabe and is also called the toothpick method, as it simulates the movement of a toothpick. This method uses a pushing motion from outside to inside, and is used in patients with gum disease or patients wearing dental implants.

Other brushing aids

Dental floss

Dental floss is used to clean the tight spaces between teeth. It is a thin thread made of nylon or plastic and is placed between the teeth and pulled to remove debris and plaque.¹⁵ Waxed flosses are easier to use as they do not break when passing through tight tooth contacts, unlike unwaxed flosses. Flossing is especially useful for children wearing braces when brushing alone cannot remove the plaque.¹⁶

Interdental brush

Interdental brushes are small and flexible brushes. They have small bristle heads that can reach areas not accessible by normal toothbrushes. They are moved through the tight contacts between teeth to eliminate the bacteria and debris present in these spaces.¹⁷

Mouthwash

Mouthwash reduces the accumulation of plaque and prevents gum diseases. It contains some active substances that kill bacteria and reduce bad odour.¹⁸ There are 2 types of mouthwash available-cosmetic and therapeutic. Cosmetic mouthwash relieves bad odour temporarily but does not act against caries or gum diseases. Whereas, therapeutic mouthwash has active ingredients that fight bacteria and prevent decay and gum disease.¹⁸ Mouthwash should be used after brushing teeth. Hold a small amount of the mouthwash for about a minute, swish and spit it out. Avoid eating or drinking anything for 30 minutes after using mouthwash to allow time for the fluoride to act.

Treatment of gum disease

Early detection and treatment of gum disease are important for the overall health of the patient. Treatment consists of some non-surgical and surgical approaches. 

Non-surgical treatment

Non surgical approach is used in patients in the initial stage of gum disease. This includes oral prophylaxis, scaling and root planing, and antibiotic therapy. Routine oral cleaning can help to relieve mild gum inflammation. Scaling and root planing achieve deeper cleaning by

removing plaque and debris from gum pockets. Antibiotics like chlorhexidine and minocycline are also used to treat the infection.¹⁹

Surgical treatment

Surgical treatment involves flap surgery, gum and bone grafting, and guided tissue regeneration. It is done in patients with moderate to severe gum disease. 

In flap surgery, cuts are made on the gum, the root and the bone surfaces are exposed, and plaque is removed (after which the gum is sutured back). Bone and gum grafts use self, donated, or artificial tissue to rebuild areas of tissue loss. Guided tissue regeneration introduces an artificial membrane between the teeth and gum, which allows for new bone growth and more stability and support for the teeth.²⁰ 

FAQs

What is a suitable rushing technique to use in gum disease?

It is recommended to use a soft-bristled toothbrush and fluoride-containing toothpaste in patients with gum disease. Place the toothbrush at a 45-degree angle to the gum line, and use a vibratory and sweeping motion from the gum to the tooth surface, along with a short back-and-forth motion while brushing. This is called the Stillman technique, indicated for patients with moderate gum disease. 

 How do I clean my tongue?

A toothbrush or tongue-scraper can be used to clean the tongue. Apply a small amount of toothpaste onto the brush or tongue scraper and gently pull it from the back of the tongue to the front. This removes any bacteria or debris on the tongue surface and also prevents bad breath.

How do I select a mouthwash?

There are 2 categories of mouthwash: cosmetic and therapeutic. If you suffer from bad breath and want temporary relief, then it is recommended that you use a cosmetic mouthwash. If you have gum disease, then therapeutic mouthwash is recommended as it contains active ingredients that kill bacteria and prevent tooth decay and the deterioration of gum diseases. 

Summary

Gum disease occurs when there is some inflammation of the gum and bone that support the teeth. Poor oral hygiene, metabolic disorders, and hormonal changes are responsible for gum inflammation. Many preventive brushing techniques have been developed for efficient plaque removal in patients with gum diseases, mainly the Stillman and Bass techniques. Brushing methods also include the use of an interdental brush, floss, and mouthwash. Treatment of gum disease involves non-surgical and surgical approaches. Gum diseases can be prevented to an extent using appropriate brushing techniques and interdental aids, along with routine dental checkups.