Stages of gum disease explained

Reviewed by Dr. Samar Fadavi, DDS

Short answer: Gum disease moves from gingivitis, where gums are red and bleed but no support is lost, to periodontitis, where the gum and bone holding the teeth start to break down. Gingivitis can be reversed with good cleaning at home and at the dentist. Periodontitis can be controlled with treatment and regular care, and the earlier it is found, the more of the tooth’s support is kept.

Why the stage matters

Gum disease is one of the most common reasons adults lose teeth, yet it is easy to miss because it often causes no pain until it is advanced. Knowing the stages helps you understand what your dentist is telling you, why certain treatments are suggested and why early visits make such a difference.

This guide walks through each stage, the signs to look for, what treatment usually involves and how to protect your gums at home. It is general information for patients in Scarborough, the Danforth and East Toronto. For how we check and care for gums at our clinic, see our family dentistry and check-ups page.

How gum disease starts

Every day a sticky film of bacteria called plaque forms on the teeth. If it is not removed by brushing and cleaning between the teeth, the gums react to it. The body sends extra blood and immune cells to the area, which is why the gums turn red, puff up and bleed easily. This is inflammation, and at first it stays in the gum tissue.

Plaque that stays on the teeth hardens into tartar, also called calculus, within days. Tartar cannot be brushed off. It gives bacteria a rough surface to grow on, both above and below the gum line. Over time, in some people, the inflammation moves deeper and starts to damage the fibres and bone that hold the teeth in place. That is when gingivitis has become periodontitis.

Not everyone with gingivitis develops periodontitis. Genetics, smoking, diabetes, stress and other health factors all affect how the body responds to plaque. That is why two people with similar brushing habits can have very different gums.

Stage 1: Gingivitis

Gingivitis is inflammation of the gums only. The bone and the fibres attaching the gum to the tooth are still intact.

Common signs:

• Gums that bleed when brushing or flossing.
• Red or darker gums instead of firm pink or evenly pigmented gums.
• Puffy gums, especially between the teeth.
• Bad breath.
• Tender gums, though many people feel no pain at all.

What helps: a professional cleaning to remove tartar, followed by brushing twice a day and cleaning between the teeth every day. With good home care, gums usually look and feel healthier within a couple of weeks. Gingivitis is reversible, which is why it is so worth catching.

Many people stop flossing when their gums bleed, thinking they are causing harm. In most cases the opposite is true: the bleeding is a sign of inflammation, and gentle daily cleaning is what makes it stop. See our guide on gum bleeding for more.

Stage 2: Early periodontitis

In early periodontitis, the inflammation has started to destroy some of the attachment between the gum and the tooth. A small pocket forms where the gum pulls away from the tooth. Plaque and tartar collect inside this pocket, where a toothbrush cannot reach.

Common signs:

• Bleeding gums that do not improve with better home care.
• Bad breath or a bad taste that keeps coming back.
• Gums starting to look slightly pulled back.
• Pocket depths at check-ups that are deeper than before.
• Early bone loss visible on x-rays.

What helps: a deep cleaning, also called scaling and root planing, to remove tartar from inside the pockets and smooth the root surfaces, followed by more frequent maintenance cleanings. Our guide deep cleaning (scaling) explained walks through the visit.

Stage 3: Moderate periodontitis

At this stage the pockets are deeper and more bone has been lost. Teeth may start to feel slightly different.

Common signs:

• Noticeable gum recession, making teeth look longer.
• Sensitivity to cold on exposed roots.
• Spaces opening between teeth.
• Slight looseness in some teeth.
• Pus at the gum line, or occasional swelling.

What helps: deep cleaning, a re-evaluation after healing and a maintenance schedule every few months. Some deep pockets may need further treatment, such as local medication or gum surgery, which may involve a referral to a periodontist, a dentist who focuses on treating the gums.

Stage 4: Advanced periodontitis

In advanced periodontitis, much of the bone support around some teeth is gone. Teeth can drift, loosen and affect how you chew and speak.

Common signs:

• Loose or shifting teeth.
• A change in your bite or how dentures or partials fit.
• Pain when chewing.
• Repeated gum abscesses.
• Teeth that have been lost to gum disease.

What helps: treatment focuses on controlling the infection, keeping as many teeth as possible and planning for any teeth that cannot be kept. This may include deep cleaning, surgical gum treatment, splinting loose teeth and, where a tooth cannot be saved, extraction and replacement with a bridge, a denture or an implant. Our guide implants, bridges or dentures? compares replacement options.

How dentists describe gum disease today

You may hear your dentist talk about stages and grades. The stage describes how much damage has already happened, based on pocket depths, attachment loss, bone loss on x-rays and teeth lost. The grade describes how quickly the disease seems to be moving and how strongly risk factors like smoking and diabetes are affecting it. Together they help your dentist plan treatment and decide how often you should come back.

You do not need to memorize these terms. The key questions to ask are simple: How healthy are my gums? Is anything getting worse? What can I do at home? When should I come back?

What happens at a gum check

1. Looking at the gums. Your dentist checks the colour, shape and firmness of the gums and looks for recession and swelling.
2. Measuring pockets. A thin, marked instrument gently measures the space between each tooth and the gum at several points. Numbers are called out and recorded. It may feel like light pressure; inflamed gums can be tender.
3. Checking for bleeding. Sites that bleed after probing are noted, because bleeding signals active inflammation.
4. Checking movement. Teeth are gently tested for looseness.
5. X-rays. Bitewing or other dental x-rays show bone levels around the teeth. Our guide to dental x-rays explains the types.
6. Talking about risk. Your dentist asks about smoking, diabetes, medicines, pregnancy and family history.

Comparing these measurements over time shows whether your gums are stable, improving or getting worse.

Risk factors you can and cannot change

Factors you can change or manage:

• Smoking and vaping. Smoking is one of the strongest risk factors for periodontitis and also hides bleeding, so the disease can progress quietly.
• Daily plaque removal at home.
• Blood sugar control if you have diabetes.
• Regular dental visits and cleanings.
• Dry mouth from medicines, which your doctor or pharmacist may be able to help with. See our guide on dry mouth and medications after 60.

Factors you cannot change:

• Family history and genetics.
• Age, since gum disease is more common in older adults, mostly because damage builds up over many years.
• Hormone changes during puberty, pregnancy and menopause.
• Certain medical conditions and treatments that affect the immune system.

If you have risk factors you cannot change, the ones you can change matter even more.

Protecting your gums at home, step by step

1. Brush twice a day for two minutes with a soft brush and fluoride toothpaste. Tilt the bristles toward the gum line and use small circles.
2. Clean between every tooth once a day. Use floss, interdental brushes or a water flosser. Interdental brushes are often easier for larger spaces.
3. Do not skip the back teeth. The inside surfaces of the lower front teeth and the back molars collect the most tartar.
4. Look at your gums once a week in good light. Notice bleeding, swelling or changes.
5. Keep regular cleanings at the interval your dentist recommends.
6. Replace your toothbrush or brush head every three months, or sooner if the bristles are frayed.

What to avoid

• Stopping flossing because your gums bleed.
• Scrubbing hard with a firm brush, which can wear gums and teeth.
• Relying on mouthwash alone. Rinses can help, but they do not remove plaque the way brushing and cleaning between teeth do.
• Waiting for pain. Gum disease often does not hurt until it is advanced.
• Trying to scrape tartar off at home with sharp tools. This can injure the gums and enamel.

Gum disease and your general health

Gum disease is a chronic inflammation, and health organizations have noted links between gum disease and conditions such as diabetes and heart disease. The connection with diabetes works both ways: gum infection can make blood sugar harder to control, and high blood sugar makes gum disease harder to control. Looking after your gums is part of looking after your whole body. Our guide to oral health and overall health explains more.

Coverage and planning

Gum assessments, cleanings and scaling are covered by many dental insurance plans, with limits that vary by plan. The Canadian Dental Care Plan includes periodontal services, with frequency limits. Our team direct bills most insurers, can send a predetermination before treatment and gives you a written estimate at your visit. See our CDCP dentist page for how the plan works here.

Gum disease at different ages

Children and teens. Children rarely have periodontitis, but gingivitis is common, especially during the teen years when hormones make gums more reactive and braces make cleaning harder. Puffy, bleeding gums around braces usually improve with careful brushing around the brackets, interdental brushes and regular cleanings.

Adults in their 30s to 50s. This is when periodontitis often begins to show on x-rays and gum measurements. Busy schedules, stress, smoking and skipped visits all play a part. Early treatment at this stage keeps far more bone support in place than treatment years later.

Older adults. Gum recession, root decay, dry mouth from medicines and reduced hand strength make gum care harder. A powered toothbrush, larger handles, interdental brushes and more frequent cleanings help. Caregivers can make a big difference by helping with daily cleaning. Our seniors’ dental care page explains how we support older patients.

Gum disease and dental work

Healthy gums are the foundation for any crown, bridge, denture or implant. Gum inflammation can make it harder to take accurate impressions, can cause bleeding around new crowns and can shorten how well dental work lasts. Around implants, a similar inflammation called peri-implantitis can damage the bone that holds the implant. For this reason, your dentist will usually want gum disease under control before starting larger treatment, and will keep checking the gums around existing dental work at every visit.

If you wear a partial denture, clean the teeth that hold the clasps very carefully, because plaque collects around them. Remove the partial at night unless your dentist advises otherwise.

When to see a dentist

Book a visit if your gums bleed for more than a week or two despite good brushing and flossing, if your gums are pulling back, if teeth feel loose or are shifting, or if you notice a persistent bad taste or bad breath. Seek a same-day visit if a gum area becomes swollen, painful or drains pus; see our emergency dentist page. For gum checks, cleanings and ongoing care, see our family dentistry and check-ups page.

Questions about gum disease

Can gingivitis go away on its own?

Not on its own, but it often improves within a couple of weeks once plaque and tartar are removed and daily brushing and cleaning between teeth become a habit.

Can periodontitis be reversed?

Bone and attachment that have been lost do not usually grow back on their own. Treatment can stop the disease from getting worse and help the gums heal, and in some cases surgical treatment can regenerate some support.

Is gum disease contagious?

The bacteria involved can be shared through saliva, but gum disease develops based on each person’s plaque control, health and risk factors.

Why don’t my gums bleed even though I smoke and have gum disease?

Smoking narrows blood vessels in the gums, which can hide bleeding. That is why regular gum measurements are important for smokers.

How often should I have cleanings if I have had periodontitis?

Many people do well with maintenance cleanings every three to four months. Your dentist will suggest an interval based on how your gums respond.

Does gum disease cause bad breath?

It can. Bacteria in gum pockets release odours. Our guide on mouth odour covers other causes too.

Is an electric toothbrush better for gum disease?

A powered brush can make it easier to clean well, especially for people with limited hand movement. A manual brush used carefully also works.