Doctors Revision

Oral & Dental Health

Periodontitis

Inflammatory disease affecting the supporting structures of the teeth (periodontal ligament, alveolar bone), leading to progressive loss of attachment and bone, pocket formation, and potentially tooth loss. It results from untreated gingivitis interacting with host immune response.

Also known as: Gum Disease (Advanced), Pyorrhoea (obsolete term)

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Referral and warning signs

When to refer

Refer ALL suspected cases of periodontitis to dental personnel (HC4+) for diagnosis, scaling and root planing, and ongoing management. Refer complex or refractory cases to Periodontist (RR).

Red flags

  • Significant tooth mobility.
  • Rapid progression of bone loss/attachment loss.
  • Associated systemic illness affecting immunity.
  • Failure to respond to standard non-surgical therapy.

Signs and symptoms

  • Signs of gingivitis (redness, swelling, bleeding gums).
  • Periodontal Pockets: Deepening of the gingival sulcus (>3-4mm) detected by probing.
  • Loss of Clinical Attachment: Measured by probing.
  • Alveolar Bone Loss: Detected radiographically.
  • Gingival recession (gums pulling away from teeth, exposing roots).
  • Tooth mobility (loosening of teeth).
  • Drifting or flaring of teeth.
  • Suppuration (pus) from periodontal pockets (may be spontaneous or on probing).
  • Bad breath (halitosis).
  • Bad taste.
  • Pain is often NOT a major feature until late stages or if abscess develops.

Risk factors

  • Poor oral hygiene / Chronic gingivitis.
  • Smoking (major risk factor).
  • Diabetes mellitus (especially poorly controlled).
  • Genetic susceptibility.
  • Certain systemic diseases (e.g., affecting immunity).
  • Stress.
  • Certain medications.
  • Malnutrition.
  • Specific bacterial pathogens (e.g., Porphyromonas gingivalis, Tannerella forsythia, Aggregatibacter actinomycetemcomitans).

Diagnosis

Clinical assessment

Based on clinical examination including periodontal probing (measuring pocket depths and attachment loss) and assessment of bleeding on probing, mobility, recession, furcation involvement.

Investigations

  • Comprehensive Periodontal Examination (Probing).
  • Dental X-rays (Periapicals, Bitewings, OPG): Essential to assess level of alveolar bone loss.

Diagnostic criteria

Clinical evidence of attachment loss and radiographic evidence of alveolar bone loss.

Management

Non-pharmacological management

  • Improved Oral Hygiene: Meticulous brushing and interdental cleaning is fundamental.
  • Professional Cleaning (Non-Surgical Periodontal Therapy):
  • - Scaling and Root Planing (SRP): Deep cleaning below the gumline to remove plaque, calculus, and smooth root surfaces. Performed by dental professionals (Dentist, Therapist, Hygienist). Requires multiple visits, often under local anaesthesia. (LOC: HC4+)
  • Smoking cessation advice and support.
  • Control of systemic risk factors (e.g., diabetes management).

Pharmacological treatment

  • Antiseptic Mouthwashes (Chlorhexidine): Used short-term as an adjunct to mechanical cleaning, especially post-SRP.
  • Systemic Antibiotics: Generally NOT used for routine chronic periodontitis. May be considered as adjunct to SRP ONLY in specific cases (e.g., aggressive periodontitis, refractory cases, certain systemic conditions) - specialist decision, often guided by microbiology.
  • Local Antibiotic Delivery: Placement of antibiotics directly into pockets (specialist use).

Surgical Management

  • Periodontal Surgery: Considered for deep pockets unresponsive to non-surgical therapy. Includes flap surgery, bone grafts, guided tissue regeneration. (LOC: Periodontist/RR)

Monitoring

Requires long-term periodontal maintenance therapy (regular professional cleaning and monitoring, typically every 3-6 months) to prevent disease progression after initial treatment.

Complications

  • Progressive bone loss.
  • Increasing tooth mobility.
  • Tooth loss.
  • Periodontal abscess formation.
  • Aesthetic problems (recession, drifting).
  • Difficulty chewing.
  • Association with systemic diseases (cardiovascular disease, diabetes complications, respiratory infections, adverse pregnancy outcomes).

Prevention

  • Preventing or effectively treating gingivitis through good oral hygiene and regular professional cleanings.
  • Smoking cessation.
  • Good diabetic control.
  • Regular dental check-ups for early detection.

Patient education

  • Explanation of periodontitis as destruction of tooth support (bone loss).
  • Irreversible nature of bone loss - treatment aims to stop progression.
  • Crucial role of patient's daily oral hygiene.
  • Need for professional deep cleaning (SRP).
  • Importance of smoking cessation and diabetes control.
  • Necessity of long-term maintenance visits.
  • Link between periodontal health and overall health.

Uganda-specific notes

Periodontitis is prevalent, often advanced due to late presentation and limited access to care. Management often limited to scaling and oral hygiene instruction where possible. Extraction common for mobile teeth.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.7

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