The good gums guide – can we finally ditch flossing?

Gum disease can increase your risk of dementia and type 2 diabetes – and 90 per cent of us have it. Here’s what to look out for and how to beat it.

There is no scientific evidence that we should clean our teeth for two minutes at a time.

Open wide and check your mouth in the bathroom mirror. If you see pale pink, firm gums that wrap tightly around your teeth, you get good marks for gum health. If, however, they are red, swollen and receding and there is a pink tinge or even blood when you swill out your mouth after brushing or flossing, it is a sign of gum disease.

What starts as a painless inconvenience can eventually cause a chronic inflammatory response in the body that raises a person’s risk of a long list of health issues, from dementia and type 2 diabetes to lung and heart disease. Age increases the chance of developing gum disease, and by the time we reach our fifties and sixties most of us are susceptible.

“About 90 per cent of the UK population has some form of gum disease,” says Iain Chapple, professor of periodontology at the University of Birmingham and head of research for its Institute of Clinical Sciences. Figures from the Great British Oral Health Report show that more than half of adults have gingivitis, early-stage gum disease characterised by inflammation and painless bleeding.

Left untreated, that can progress to full-on periodontitis, which occurs when bacteria in the mouth erode the bone, ligament and tissues that hold teeth in position. Teeth begin to wobble and dislodge – although the aesthetic consequences should be the least of our concerns.

“Localised inflammation caused by gum disease can result in bacteria and inflammatory by-products spilling into the blood,” says Praveen Sharma, an associate professor in restorative dentistry at the University of Birmingham and a scientific adviser to the British Dental Association. “When that happens it can cause body-wide inflammation that leads to a raised risk of systemic disease.”

There is a strong association between poor gum health and some diseases. Picture: Thinkstock.

A slew of studies supports the strong association between poor gum health and a list of diseases, including a 37 per cent increased risk of mental ill health, a 26 per cent raised risk of type 2 diabetes and an 18 per cent higher risk of cardiovascular disease identified by a team at the University of Birmingham.

A recent trial that tracked a group of men for 50 years found that the more severe the inflammation and gum disease, the higher the risk of dying at a younger age. “[Gum disease] delivers a chronic inflammatory burden, and the longer you have that inflammatory burden, the higher the risk of death,” says Brenda Heaton, associate professor of health policy and health services research at Boston University.

Poor gum health has also been linked to high blood pressure and an irregular heartbeat in patients with existing heart disease. Last month Japanese researchers reported how gum problems are associated with shrinkage of the hippocampus, the part of the brain that plays a role in memory, and that even in people with mild gum disease the increase in brain shrinkage was equivalent to nearly one year of accelerated brain ageing. That study followed findings from the Forsyth Institute of dental research and Boston University that bacteria associated with gum disease can produce changes in microglial cells in the brain that defend against the formation of amyloid plaque, a marker of Alzheimer’s disease.

If only we spent more time trying to ensure the health of our gums and less obsessing on how to whiten our ivories to look as pearly as A-listers such as Tom Cruise.

“We have this massive issue where the appearance of white teeth and a cosmetic smile is considered more important than our oral health,” Chapple says. “People think a bit of gingivitis is normal and trivial and don’t really focus on improving it, and yet studies have shown that if you treat it in the early stages it can affect how your body’s white blood cells behave, making them less inflammatory. [It can] also reduce levels of harmful C-reactive protein, produced by the liver when there is inflammation present in the blood that raises the risk of disease.” By taking care of our gums we can prevent ill health down the line. Here’s how:

A healthy diet can help prevent gum disease. Picture: Thinkstock.

How do I spot gum disease?

Early on it can be symptomless. “The most obvious visible sign in non-smokers is bleeding gums, a sign that your gums are inflamed,” says Faizan Zaheer, a specialist in periodontology and a dentist for Bupa. “If you look closer, your gums will look red and swollen.” Smoking causes constriction of the blood vessels in the mouth, so warning signs are less obvious. “Smokers might have inflammation but don’t spot gum disease because there is no bleeding. You have to be extra vigilant and have regular check-ups if you have any signs of gum disease, but particularly if you smoke.”

Your taste and smell can also be affected. “Some people with gum disease report a metallic aftertaste in their mouth,” Zaheer says. “But this varies massively from person to person.” Loose teeth are a sign that gum disease is at an advanced stage, at which point you might also develop gum infections resulting in an abscess and seeping pus, which can be tasted.

Can I stop it in its tracks?

Gum disease develops when the film of bacteria that sticks to our teeth causing plaque is not brushed away. Eventually it tunnels into the gum line. Your susceptibility to gum disease largely depends on two factors: family history of the condition and the degree of plaque build-up. “Some people are genetically more susceptible to it than others,” Zaheer says. “If you take plaque out of the equation for anyone, then gum disease will improve for everyone – although people with a high genetic risk of gum disease will have to work harder at removing plaque in the first place.”

The good news is that you can always improve the prognosis by going back to basics: using a toothbrush held at a 45-degree angle to the gum line twice a day, along with diligent interdental brushing. Gingivitis can be reversed, but more advanced periodontitis can only be slowed. “It’s important to see your dentist and hygienist as well, as there is plenty that can be done,” Zaheer says.

Should I clean my teeth for longer than two minutes?

“There is absolutely no scientific evidence for the two-minute brush,” Chapple says. Depending on the state of your gums and individual risk, you need to spend “anywhere between six and ten minutes twice a day”, he says, in what he describes as “one heck of a commitment”.

In between brushes consider using mouthwash. “A big review of mouthwashes by a team of Spanish researchers found that they do provide additional benefits for our gums in reducing inflammation and bad bacteria in our mouths. It is probably best to swill in between brushes for any added protection.”

Do I really need to keep flossing?

“Brushing won’t remove more than 80 per cent of the plaque in your mouth so it is not enough on its own,” Zaheer says. “Historically flossing was the go-to mechanism for plaque removal and while it’s still better to floss than do nothing, research now suggests that interdental brushes are a lot more effective.”

Floss should not be sidelined completely. “If gaps between the teeth are too tight, floss can be used instead,” Zaheer says. Interdental brushes come in a variety of sizes and are colour-coded. For one to be effective it needs to fit as tightly as possible between your teeth without it hurting. “If the brush is not a snug fit it won’t be scrubbing up against the walls of the teeth,” Zaheer says. “It’s best to have a range of sizes to use in different-sized gaps.” Rinse after use and dispose when the bristles become splayed and damaged, which is usually after a week or two.

There is some evidence that keeping fit can help gum health.

Can eating certain foods help?

Diets low in refined carbs and sugars are optimal for gum health. “That helps to reduce background inflammation in the body and early evidence suggests that improves gum health too,” Chapple says. Washington University researchers reviewed 15 studies involving 1,140 mostly healthy people for a paper in Nutrition Reviews and found that those who had gums that bled upon gentle probing were more likely to have low levels of vitamin C in their bloodstreams. Eating more kale, peppers and kiwis was recommended.

“A healthy, balanced diet with plenty of vitamin C from food sources such as fresh fruit and vegetables is best for gum health,” Zaheer says.

Early studies suggest that intermittent fasting may also be helpful. In a recent review by Luigi Nibali, professor of periodontology at King’s College London, short-term calorie restriction of 500-1,300 calories per day was shown to be helpful in reducing gum pockets, although Nibali and his team say more research is needed.

What are gum pockets?

With advanced disease, gums begin to pull away from the teeth, creating “periodontal pockets” between the teeth and gums. Over time, as these pockets become deeper and more difficult to clean, they gather bacteria and gradually the bone anchoring the teeth in the jaw is worn away so the teeth become loose. “Dentists use a probe to measure the depth of a pocket in millimetres and the deeper a pocket, the worse the gum disease,” Zaheer says. “A pocket of 4mm or greater in depth signifies some gum disease, with a 5-7mm pocket a sign of moderate periodontitis, and deeper than that is advanced gum disease and likely loose teeth.”

Treatment options depend on the severity of the problem. With small gum pockets you will be advised to step up your oral hygiene practice to remove the plaque. “Studies have shown that 50 per cent of mild gum pockets can reduce [in size] by improving your brushing at home. The first stage of treatment for more advanced pockets would involve professional scaling or deep root cleaning to clear out the bacteria living below the line of the gum and reduce inflammation.” In severe cases where other steps haven’t worked surgery may be required, involving a periodontist lifting or “flapping” the gums away from the teeth and bone so that deposits can be removed from the root surface.

Could exercise help?

Keeping active is known to help to reduce inflammation in the body, Chapple says, and some researchers have found that it has specific benefits in warding off gum disease. One report in the journal Nature suggested that active people were 54 per cent less likely to suffer advanced gum disease than sedentary people. “Since excess weight is a risk factor for unhealthy gums and activity helps to keep weight down, regular exercise is important in many ways for gum health,” Chapple says.

The Times

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