Periodontitis

Periodontitis is a chronic multifactorial inflammatory disease of the tooth supporting tissues (gingiva, periodontal ligament, cementum and alveolar bone) driven by a dysbiotic plaque biofilm and the host response to it, leading to irreversible loss of clinical attachment and alveolar bone. Severe periodontitis affects about 10 percent of adults worldwide, and moderate disease up to 40 to 50 percent. It is a leading cause of tooth loss in adults.

Key organisms are Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola and Aggregatibacter actinomycetemcomitans. Tissue destruction comes from host matrix metalloproteinases, prostaglandin E2, IL-1 and TNF-alpha.

Staging uses the degree of attachment loss and bone loss: stage I (1 to 2 mm interdental clinical attachment loss), stage II (3 to 4 mm), stage III (5 mm or more, with tooth loss up to 4 teeth), stage IV (5 mm or more with loss of 5 or more teeth and loss of masticatory function). Grade A, B, C reflects rate of progression.

Risk factors are smoking, diabetes (poor control triples the risk), poor oral hygiene, HIV infection, genetic factors, stress and obesity. Associations include cardiovascular disease, adverse pregnancy outcomes and poor glycaemic control.

• Gingival redness, swelling, bleeding on brushing, halitosis, and altered taste.
• Gingival recession, apparent lengthening of teeth, interdental spaces, food impaction.
• Tooth mobility, drifting, tooth migration, change in bite.
• Periodontal pockets with suppuration; recurrent periodontal abscess (localised swelling, pain, pus from pocket).
• Pain is often absent until late.
• Furcation involvement on multirooted teeth; deep vertical bone defects.
• Red flags: rapid attachment loss in young adults (aggressive pattern), necrotising features, systemic disease (diabetes, leukaemia, HIV), and spreading facial infection.

• Full mouth periodontal charting with a calibrated probe at 6 sites per tooth: probing depth (normal 1 to 3 mm), clinical attachment loss (measured from cement enamel junction), bleeding on probing, recession, mobility (Miller grading 1 to 3), furcation involvement.
• Case definition: interdental clinical attachment loss at 2 or more non-adjacent teeth.
• Radiographs: periapical and bitewing or panoramic view show horizontal or vertical bone loss, measured relative to root length (under 15 percent coronal third in stage I, over 33 percent mid-root in stage III).
• Plaque and calculus scores.
• Screen for modifiers: HbA1c, HIV test, full blood count and film when disease is severe and young onset.
• Microbial culture and sensitivity only for refractory disease.
• Exclude gingivitis, necrotising periodontal disease, endodontic periodontal lesion, occlusal trauma, gingival enlargement, and leukaemic infiltration.

• Step 1 (behaviour): oral hygiene instruction, interdental cleaning (brushes 0.6 to 0.8 mm), twice daily brushing with fluoride toothpaste 1450 ppm, smoking cessation, glycaemic control (target HbA1c under 53 mmol/mol or 7 percent), risk factor management.
• Step 2 (cause related therapy): supragingival scaling, then subgingival instrumentation (scaling and root surface debridement) under local anaesthetic (lidocaine 2 percent with adrenaline 1:80 000, up to 4.4 mg/kg, maximum 7 mg/kg with vasoconstrictor), over 2 to 4 visits.
• Adjuncts: chlorhexidine gluconate 0.2 percent mouthwash 10 mL rinsed for 1 minute twice daily for up to 2 weeks (staining and taste change are main adverse effects); doxycycline 20 mg orally twice daily for 3 months (sub-antimicrobial dose) may reduce collagenase.
• Systemic antibiotics are only for severe, generalised, rapidly progressive disease (grade C, stage III or IV, aged under 35 years) or acute spreading infection: amoxicillin 500 mg with metronidazole 400 mg orally three times daily for 7 days, started on the day of instrumentation (penicillin allergy: azithromycin 500 mg once daily for 3 days with metronidazole 400 mg three times daily for 7 days).
• Reevaluation at 6 to 12 weeks: residual pockets 5 mm or more or 4 mm with bleeding need step 3.
• Step 3 (surgical therapy): open flap debridement, guided tissue regeneration with bone graft, enamel matrix derivative for intrabony defects, resective surgery, root resection or extraction for hopeless teeth; implants only after disease control.
• Periodontal abscess: drain through the pocket, debride, and use metronidazole 400 mg three times daily for 5 days when systemic features occur.
• Step 4 (supportive care): maintenance recall every 3 months (shorter intervals for high risk), reassessment of probing, radiographs every 2 to 3 years.
• Special populations: diabetes (control improves outcome; give treatment in the morning after normal meal), pregnancy (treat in the second trimester), HIV (treat aggressively, monitor CD4).
• Counselling: lifelong plaque control, smoking cessation, and risk of tooth loss.