Bone loss around your teeth, and what can still be done

Each tooth is held in its socket by fine fibres attached to the surrounding bone. On a healthy X-ray that bone reaches up close to where the enamel ends; bone loss means the level has moved down the root. It is measured in two ways, because each shows something the other cannot: the X-ray shows the bone, and a gentle probe shows how deep the space between gum and root has become. Together they place the loss on the 2018 scale, which stages periodontitis by how far the breakdown reaches relative to the length of the root, and by how complex it is to manage: pocket depth, bony defects beside a root, involvement of the area between the roots of back teeth, and mobility.^[1]

A stage is not a verdict on how your gums are today. The 2018 classification recognises that gums can be healthy on a reduced level of bone, including in people whose periodontitis has been treated and is now stable, and it also notes that a treated patient stays at higher risk of it returning and should be monitored closely.^[4] So the useful questions are how much has been lost, whether it is still moving, and what will keep it where it is. Bring any earlier X-rays you have to the first visit: comparing them with today's shows whether the bone level is still changing, which is what the grade describes.^[1]

Around natural teeth, the usual reason is periodontitis. Bacteria in the plaque below the gum line keep the gum inflamed, and over time that inflammation breaks down the fibres and bone that hold the tooth. Gum disease and tooth decay are the most common diseases people have, and together they are the main cause of tooth loss.^[5]

After a tooth is taken out, the bone that held it shrinks. A systematic review of human studies found the ridge lost 29 to 63% of its width and 11 to 22% of its height within six months, most of it in the first three to six months.^[6] That is a different problem from gum disease, and it matters when a gap is going to be filled.

Bone can also be lost around a dental implant. The 2017 world workshop separates two stages: peri-implant mucositis, where the gum around the implant bleeds on gentle probing and plaque is the cause, and peri-implantitis, where that inflammation is followed by progressive loss of the supporting bone. It also recommends a baseline X-ray and probing once the implant crown is fitted, so that any later change can be measured against it.^[7] Each of the three is handled differently, so the first visit starts by establishing which one, or which combination, you have.

Some people lose bone faster than others with the same amount of plaque, and the reasons are worth knowing because several of them can be changed. Diabetes is one: a review of 13 long-term studies found it raised the risk of periodontitis starting or getting worse by 86%.^[8] Smoking is another, with a second effect that matters: it suppresses gum bleeding, so the usual warning sign is quieter in smokers.^[9] In a Saudi study, men who smoked a waterpipe (shisha) and men who smoked cigarettes both had more attachment loss, more bone loss on X-rays and more missing teeth than men who had never smoked, while bleeding less.^[10]

Age and family play a part too. Worldwide, severe periodontitis affects about 11% of adults, and it rises steeply between the thirties and the forties, with new cases peaking at around 38.^[11] Genes are estimated to account for up to half of a person's susceptibility to gum disease.^[5] In women after the menopause, osteoporosis has been linked in observational studies with more attachment loss, deeper pockets and more bleeding, although the pooled data showed no difference in the height of the bone between the teeth, so the link is an association rather than a proven cause.^[12]

None of these is a reason for alarm on its own. They are reasons to tell us about your health, your medicines and whether you smoke or use shisha, because they change how the plan is built and how often your gums should be checked.

That is the main aim of treatment, and the evidence for it is good. Periodontitis is preventable, and treating it reduces the rate at which teeth are lost.^[13] Treatment follows four steps set out in the European guideline.^[14] The first is for everyone: daily cleaning at home, including between the teeth, professional cleaning above the gum, and bringing risk factors such as smoking and diabetes under control. The second is cleaning the root surfaces below the gum, the treatment most people know as a deep cleaning. The third is for sites that have not responded, and can include surgery. The fourth is supportive care, at intervals of 3 to at most 12 months set from your own risk.^[14]

The second step does measurable work. In the review behind that guideline, pockets were on average 1.4 mm shallower six to eight months after deep cleaning, and about three in four had closed.^[2] What holds the result is the fourth step: across eight studies that followed patients for at least five years, those who attended supportive care regularly had a 44% lower risk of losing teeth than those who attended erratically.^[3]

The part you do at home matters as much as the visits. Interdental brushes are the device of choice for cleaning between the teeth wherever they fit, and cleaning between the teeth once a day is the recommendation for people with inflamed gums.^[13] Your next step is a chart, so that the plan starts from your own numbers.

Not by itself. Once bone has been lost around a tooth, the body does not rebuild it to its old level, even when the gum disease is under control. What can change is the shape of a defect, and in selected cases part of the lost bone can be regenerated.

Where a narrow, deep defect sits beside a root, known as an intrabony or vertical defect, and a deep pocket remains after deep cleaning, the European guideline recommends regenerative surgery for defects 3 mm deep or more.^[14] Deep cleaning on its own may also do more than was once thought: in a 2025 commentary, two periodontists argue from the published evidence that it changes the shape of the bone as well, particularly in these defects, and that it should be used to its full potential before surgery.^[15]

Dr. Khalid, our periodontist and the team plan regenerative surgery together before anything is booked, from the same charts and X-rays, so no step is missed and the finished result meets the standards of function, aesthetics and biomimetics. The finished tooth is agreed first and becomes the brief; our periodontist, who works in the same clinic, carries out the surgery to it; and Dr. Khalid stays on your case, restores the tooth where it needs it, and reviews the result with our periodontist. What the surgery involves is explained on gum surgery.