Key Highlights
- Bone loss doesn’t always mean active disease: Patients may have a reduced but stable periodontium with no bleeding or pocketing, often from past periodontal breakdown.
- Not all bone loss is periodontal: Orthodontics, anatomy, occlusal trauma, thin biotype, or extractions can cause noninfectious bone loss without requiring a periodontitis diagnosis.
- Treat what you see, then monitor: If inflammation is absent, focus on preventive or periodontal maintenance care and closely track changes over time.
Recently, I asked a group of dental hygienists and dental hygiene students online what their biggest question was when it came to periodontal therapy and treatment. I thought for sure the answers would be about getting into deep pockets for removal of calculus, or at what point they should refer to a specialist for treatment and next steps. But I was wrong. Can you guess what that question was?
What happens when a patient has bone loss, but no bleeding or pocketing? How should I treat this patient?
This is such a great question. We see patients regularly with bone loss, either interproximal or on the facial surfaces, but the rest of their gingiva looks, feels, and records within normal probing depths and no bleeding. It can also be confusing since we’re used to connecting bone loss with periodontal disease, and periodontal disease with bleeding and pockets. So, what happens when a patient has bone loss but no bleeding?
Unfortunately, there isn’t one clear-cut answer on how to treat these patients. However, since we are working with humans who are all complex and unique, there are a few situations we need to think about and critically think through before creating a treatment plan.
No. 1: The patient may have “reduced periodontium” due to previous disease but is stable when it comes to bone loss progression.
If you see bone loss on radiographs without clinical signs of inflammation (no bleeding, no erythematous margins, no edema) and the probing depths are within normal limits, this could mean the patient has a history of periodontal destruction, but not active disease. Asking the patient their periodontal health and treatment history can help make this decision to see if the progress of bone loss was due to previous inflammation.
This patient is classified as:
- Periodontally stable
- Stage I–III, Grade A/B, depending on past severity1
- On a reduced but healthy periodontium
In other words, the bone is gone, but the disease process is not currently active. If this patient does have bone loss based on previous disease, they should have an AAP Classification stage and grade attached to their bone health. When it comes to treatment, the patient does have the risk factors for periodontal disease since they have had it in the past, and it can put them in a higher risk to have active disease again.2
No. 2: Your patient could have bone loss that is not infection/periodontitis related.
This happens all the time! It’s not ideal, but bone loss can occur from:
- Past orthodontic movement
- Anatomical variations in both teeth and bone
- Thin biotype
- Past extractions, especially around extracted wisdom teeth sites3
- Occlusal trauma/clenching/grinding
- Localized restorations or defects
- Decreased bone density4
These areas of bone loss are present in our patient populations and can cause issues since there is less bone present in an area. However, since this destruction is not from an infection, the patient does not need an AAP diagnosis/stage or grade.1
So, how do you treat a patient with bone loss but no bleeding/pocketing?
You treat the current condition.
If there are no signs of active periodontal disease but the patient has bone loss, then no periodontal debridement is indicated.
Instead, you provide preventive/maintenance care:
Place the patient on a periodontal maintenance schedule if they have a history of periodontitis. Since they have the risk factors of periodontal disease, there is a higher chance the disease process will return. The AAP states “a periodontitis patient is a periodontitis patient for life” and should not be treated the same as an individual who has never had a periodontal disease diagnosis.5
If bone loss is nonperiodontal or minimal, and the patient has never had periodontal disease, a prophylactic/preventive treatment may be appropriate.
Monitor closely
Since changes can quickly occur, taking proper probe depths and recession and mobility measurements at least yearly is important to be able to notice slight changes. Educating the patient on their condition is key to proper maintenance. We can explain they have less bone support than we usually like to see, which means there is less bone holding the teeth in place. Then, include proper oral hygiene education with both home care techniques and systemic health support to keep inflammation down. After great home care, educate your patient to monitor at home. If they notice bleeding, mobility, or changes in the gingiva, as clinicians we would want to see them sooner than their regular recall to help prevent further destruction of the bone.
Bone loss without bleeding or pocketing usually means a patient has a reduced but stable periodontium. Treat them based on current inflammation and their history: if they’re stable, perform preventive/prophylactic or periodontal maintenance care and carefully monitor over time.
The next time you have a patient in your operatory who has bone loss, ask a few helpful questions to learn more about them, find out about their history of disease, and then treat them accordingly.
Editor's note: This article appeared in the January/February 2026. print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
- Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions – introduction and key changes from the 1999 classification. J Periodontol. 2018;89(Suppl 1):S1-S8. doi:10.1002/JPER.18-0157
- Dental Recall: Recall Interval Between Routine Dental Examinations. London: National Collaborating Centre for Acute Care (UK); 2004. (NICE Clinical Guidelines, No. 19.) Appendix G, Implementing the clinical recommendations – selecting the appropriate recall interval for an individual patient. https://www.ncbi.nlm.nih.gov/books/NBK54548/
- Elovic RP, Hipp JA, Hayes WC. Maxillary molar extraction causes increased bone loss in the mandible of ovariectomized rats. J Bone Miner Res. 1995;10(7):1087-1093. doi:10.1002/jbmr.5650100713
- Khunthananithi P, Lertpimonchai A, Sritara C, Srithanyarat SS, Thienpramuk L, Mongkornkarn S. Decreased bone mineral density is associated with an increased number of teeth with periodontitis progression: a 5-year retrospective cohort study. Clin Oral Investig. 2023;28(1):51. doi:10.1007/s00784-023-05463-8
- Frequently asked questions on the 2018 Classification of Periodontal and Peri-Implant Diseases and Conditions. American Academy of Periodontology. 2019. https://www.perio.org/wp-content/uploads/2019/08/2017-World-Workshop-on-Disease-Classification-FAQs.pdf
About the Author
Melia Lewis, MEd, RDH
Melia Lewis, MEd, RDH, is a dedicated clinical dental hygiene professional with a passion for advancing oral health education and patient care. She practices at Aspen Heights Dental in Highland, Utah, and is an adjunct professor at Colorado Northwestern Community College. She is cofounder of Hygiene Edge, an online education platform full of helpful tips to make dental professionals' lives easier, and she owns and operates Acuti Sharpening, a dental hygiene instrument sharpening company. Contact her at [email protected] or on Instagram @hygieneedge and @meliardh.