Infection Stage

• Clinical Definition: Deep destruction of supporting periodontal tissues and alveolar bone due to the hyper-inflammatory response of the host to the bacterial infection.

• Critical Indications: Spontaneously bleeding gums, throbbing toothache, bad breath, presence of pus in the crevice between gum and tooth, or loosening of teeth. 

• Treatment Options: Scale and root plane, deep non-surgical pocket cleaning using antimicrobial agents, flap surgery, laser periodontitis treatment, or placement of a bone graft.

• Visible Changes: Swollen gums, reddish purple coloration, exposed yellow root surfaces due to gum recession, and/or purulent exudate (pus) draining from the gum crevice.

• Tactile & Sensory Changes: Throbbing toothache when biting down on food, increased mobility of the tooth, inflammation/tenderness of the lymph nodes located in the lower portion of the jaw area (submandibular lymph nodes), and/or an unpleasant metallic or salt-like sensation in the mouth.

•  Systemic Symptoms: Facial swelling (particularly rapid onset), inability to swallow or open mouth (trismus) caused by sudden constriction of muscles in the mandible (lower jaw), or fever greater than 100.4°F (38°C).

• Aggressive Loss of Tooth Structure: Teeth begin to shift rapidly causing gaps to form between teeth, severe toothaches that interfere with sleep patterns, or spontaneously bleeding gums after eating.

• Maturation of Biofilm: Dental plaque is a structured microbial biofilm—composed of organized bacteria adhering to the tooth surface within a protective extracellular matrix—rather than simple food debris. If left uncleaned and given time to accumulate, plaque will develop into a hardened calculus.

• Colonization of Subgingival Bacteria: Anaerobic microorganisms such as Porphyromonas gingivalis invade beneath the gumline where they are deprived of oxygen. This causes an exaggerated inflammatory response resulting in additional tissue destruction.

• Dietary Patterns: Nutritional deficiency and high glycemic diet can promote systemic inflammation and suppress the host’s immune defence system.

• Smoking/Tobacco Usage & Betel Nut/Areca Nut Consumption: Smoking/chewing tobacco/betel nut/consumption of areca nuts can cause vasoconstriction of blood vessels in the gum tissue. Although this may mask initial signs of gum bleeding as well as other early symptoms associated with acute dental infections, it increases the potential for advanced bone resorption.

• Other Systemic Risk Factors: Presence of poorly controlled type-2 diabetes mellitus, chronic stress, hormonal changes, and familial history.

• Oral Mirror Evaluation: Cleanse your hands, position yourself near a high-intensity light source, and gently lift your upper lip. Evaluate for red edges along the gum border, exposure of yellowish root surface, and/or evidence of deep crevice areas between the gum margin and tooth surface.

• Palpable Gum Assessment: Place your index finger against your gum margin and apply gentle pressure. Examine for any signs of pus drainage or bleeding.

• Tooth Mobility Test: Apply moderate pressure to individual teeth with your index finger placed between your thumb and forefinger. Healthy teeth should exhibit little-to-no movement.

• Periodontal Probe Analysis: The periodontist utilizes a calibrated probe to assess pocket depth circumferentially around each tooth. Pocket depths greater than 4mm typically suggest a present infection.

• Radiographic Examination: Take intraoral x-ray images or use an Orthopantomogram (OPG) radiograph to determine degree of alveolar bone loss at the base of each tooth.

• Assessment of Pulp Vitality/Microbiology: Evaluate for possible coexisting endodontic lesions by assessing pulp vitality via thermal testing or microbiologically examining samples collected from diseased areas.

• Deep Non-Surgical Debridement: Under local anesthesia, scaling and root planing (SRP) to remove the plaque/tartar from the gum line and smoothen the surface of the roots.

• Targeted Antimicrobial Treatment: Localized application of sustained release antibiotics into infected sites using gel or chip.

• Surgical Periodontal Therapy: Surgical flap opens the tissues for debridement; may include bone grafting, guided tissue regeneration (GTR), or LANAP (laser assisted) therapy.

Costs are based on private clinical costs throughout rural/semi-rural and urban Kerala (Kochi, Thiruvananthapuram, Kozhikode).

• Scaling and root planning of entire mouth: ₹2,500 – ₹6,000

• Laser periodontal pocket therapy: ₹8,000 – ₹18,000

• Bone grafting per quadrant with flap surgery: ₹6,000 – ₹15,000
   

Insurance coverage: State empaneled schemes will cover all in-patient surgical treatments at an approved hospital center.

• General Dental Practitioner: Good starting point for early screening, regular cleaning, and initial diagnosis.

• Periodontist: Gum specialist needed for measurement of greater than 5 mm of pocket depth, flap surgeries, bone regeneration, and severe laser periodontitis care.

• Endodontist: May need to consult if infection extends into the pulp chamber of the tooth requiring simultaneous root canal treatment.

• Emergency Treatment (2–6 hours): Acute periodontal abscess with increasing swelling of the face, high fever, extreme/uncontrollable pain.

• Prompt consultation (24–48 hours): Pus visible in gum crevices, acute tooth loosening or constant bleeding of gums that does not stop even after meals.

• Regular Treatment (within 1–2 weeks): Slight gum recession, chronic halitosis/bad breath, or scheduled maintenance full mouth cleaning/deep cleaning.

1. Can deep gum infections be healed fully with home remedies such as salt water rinse?
   No. Salt water rinses provide short-term relief to superficially inflamed gum tissue but can never extract calculus deposits or kill anaerobic bacteria present within >5mm deep periodontal pockets. Therefore, patients always require professional dental cleaning or SRP.

2. Does a surgical flap to treat gum infection cause significant pain?
   Because this is done entirely under local anesthesia, you have no pain while undergoing treatment. Mild discomfort lasting 3–5 days after the surgery is typically managed through over-the-counter anti-inflammatory medication.

3. Will my loose teeth stabilize after I complete the periodontal treatment?
   In most instances where there is moderate bone loss caused by the periodontal disease, removing the infection and closing the space with attached gingiva usually stabilizes the tooth. However, in some cases due to extensive bone loss, it may be necessary to use temporary splints or perform a bone graft to stabilize mobility.

• Diabetes/Cardiovascular Diseases: The same pathogens causing periodontal disease enter the bloodstream, promoting systemic inflammation and further exacerbating diabetes management.

• Periapical Abscess/Endo-Perio Lesions: When the infection from the gum travels down the length of the tooth until it reaches the root end and infects the inner pulp chamber nerve.

• Peri-Implantitis: Identical type of bacterial infection surrounding a dental implant which causes progressive bone loss.

• Supportive Periodontal Maintenance Therapy (every 3–4 months): After treating the patient’s infection stage of periodontal disease, support their continued health with ongoing professional cleaning services.

• Custom Night Guards/Occlusal Adjustments: Provide comfort for loose teeth that are still healing by reducing uneven biting pressures applied to those areas.

• Restorative Fillings/Crown Lengthening: Repair broken adjacent teeth near infected gums to remove trapped bacteria and create an environment that supports healthy recovery.

To address the infection phase of periodontal disease requires two approaches: First clinically intervene immediately to eliminate subgingival pathogens. Second, establish a good quality regimen for a patient's personal at-home oral hygiene. If left untreated, chronic infection will lead to irreparable loss of alveolar bone and result in premature tooth loss. New periodontal therapies combining ultrasonic debridement targeted local antimicrobials and regenerative laser treatments allow for arrestment of disease progress and preservation of patient's natural smile for life. Consult a board-certified periodontist when symptoms such as swollen gums or pus appear.