Gingivitis and periodontitis
Exam Tips
- In UK exams, distinguish reversible gingivitis (bleeding/inflammation without attachment loss) from periodontitis (attachment loss, pocketing, bone loss, mobility).
- ANUG clue: painful punched-out interdental papillae with pseudomembrane and fetor; lesions are usually confined to gingiva, unlike herpetic gingivostomatitis.
- State that GPs should identify red flags and refer for dental assessment; definitive diagnosis requires periodontal probing and often radiographs.
- Always mention modifiable risks (smoking, glycaemic control, oral hygiene) and that antibiotics are not routine for uncomplicated chronic periodontal disease.
- Common station pitfall: missing medicine-related gingival enlargement (especially phenytoin, nifedipine, ciclosporin).
Definition
Gingivitis and periodontitis are plaque-driven inflammatory diseases of the periodontal tissues, with gingivitis confined to the gingiva and periodontitis extending to the periodontal ligament and alveolar bone. Gingivitis is potentially reversible with effective plaque control, whereas periodontitis causes cumulative attachment loss, periodontal pocketing, tooth mobility, and possible tooth loss. Acute necrotizing ulcerative gingivitis (ANUG) is a painful, rapidly progressive necrotizing form with ulcerated interdental papillae and bleeding.
Pathophysiology
Dental plaque biofilm accumulates at the gingival margin; within days, bacterial products trigger a host inflammatory response. Early dysbiosis includes increased Gram-negative anaerobes (for example Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola), and persistent inflammation shifts from reversible superficial gingivitis to destructive periodontitis in susceptible hosts. In periodontitis, immune-mediated connective tissue breakdown and osteoclast-driven alveolar bone resorption lead to apical migration of the junctional epithelium, periodontal pocket formation, and progressive attachment loss. ANUG is linked to anaerobic flora (including Fusobacterium nucleatum, Treponema species, Prevotella intermedia) with tissue necrosis, pseudomembrane formation, severe pain, and fetor. See Figure: progression from healthy gingiva to gingivitis, pocketing, and bone loss in standard periodontology diagrams.
Risk Factors
- Inadequate oral hygiene and persistent plaque/calculus
- Current cigarette smoking
- Diabetes mellitus, especially poor glycaemic control
- Local retentive factors (crowding, overhanging restorations, partial dentures)
- Older age
- Immunocompromise
- Xerostomia-inducing medicines (for example antidepressants, antihistamines)
- Poor diet and psychosocial stress
- Pregnancy/puberty hormonal change (more gingival inflammation)
- ANUG-specific: smoking, malnutrition, stress, immunocompromise, poor oral hygiene
Clinical Features
Symptoms
- Gingivitis often minimally painful; bleeding during brushing/flossing or when eating firm foods
- Periodontitis often painless until late disease
- Halitosis or foul taste
- Root sensitivity from gingival recession
- Tooth drifting/loosening and reduced chewing efficiency
- ANUG: sudden severe gingival pain, spontaneous or easily provoked bleeding, anorexia, malaise, occasionally fever
Signs
- Erythematous, swollen gingival margins with bleeding on gentle probing
- Periodontal pockets with possible pus/debris expression
- Gingival recession and clinical attachment loss
- Tooth mobility, migration, and possible tooth loss
- Periodontal abscess in some cases
- ANUG: punched-out necrotic interdental papillae with grey/yellow pseudomembrane, cervical lymphadenopathy, marked fetor
Investigations
Management
Lifestyle Modifications
- Urgent referral to a dentist for confirmation and definitive periodontal care
- Twice-daily toothbrushing with fluoride toothpaste and daily interdental cleaning
- Professional plaque/calculus removal and tailored oral-hygiene instruction
- Smoking cessation support
- Optimise diabetes control and nutritional status
- Stress reduction and hydration/oral dryness management
Pharmacological Treatment
Antiseptic mouthwash
- Chlorhexidine gluconate 0.2% mouthwash: rinse 10 mL for 1 minute twice daily for up to 4 weeks
Adjunct to mechanical cleaning, not a substitute. Warn about reversible tooth/tongue staining, taste disturbance, and increased calculus deposition; avoid prolonged continuous use.
Systemic antibiotic (only selected cases, e. g. ANUG with systemic involvement or spreading infection)
- Metronidazole 400 mg orally three times daily for 3 days (may extend to 5 days based on clinical response)
Not routinely indicated for uncomplicated chronic gingivitis/periodontitis. Contraindications/cautions: alcohol interaction (and for 48 hours after course), warfarin interaction (raised INR), avoid in first trimester where possible, dose-caution in severe liver disease.
Analgesia
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day)
- Ibuprofen 400 mg orally up to three times daily with food when required
Use lowest effective dose for shortest duration. Avoid NSAIDs in peptic ulcer disease, severe renal impairment, NSAID-exacerbated asthma, heart failure, or anticoagulated patients unless risk-assessed.
Surgical / Interventional
- Non-surgical periodontal debridement/root surface debridement by dental team
- Periodontal surgery for persistent deep pockets after initial therapy (for example flap access surgery)
- Management of periodontal abscess (drainage/debridement) where indicated
- Extraction of teeth with hopeless periodontal prognosis
Complications
- Progressive periodontal attachment and alveolar bone loss
- Recurrent periodontal abscesses
- Deepening pockets and gingival recession
- Tooth mobility, drifting, and eventual tooth loss
- Impaired mastication, nutrition, and quality of life
- ANUG recurrence or progression to necrotizing ulcerative periodontitis
- Rarely in severe malnutrition/immunocompromise: noma (orofacial gangrene)
Prognosis
Gingivitis has an excellent prognosis when plaque control is restored and risk factors are addressed. Periodontitis is chronic and tissue loss is largely irreversible, but progression can usually be slowed or stabilised with sustained professional and home care. ANUG typically improves within days after prompt debridement, hygiene measures, and selective antimicrobial therapy; delayed or inadequate treatment increases recurrence and destructive sequelae.
Sources & References
✅NICE Guidelines(1)
- Gingivitis and periodontitis[overview]