Periodontitis

Periodontitis is a chronic inflammatory disease resulting from progression of untreated gingivitis into deeper periodontal supporting tissues. The condition affects the periodontal ligament, cementum, and alveolar bone, leading to formation of periodontal pockets, connective tissue destruction, and progressive bone loss.

As periodontal destruction advances, pathogenic bacterial colonization increases, resulting in tooth mobility and eventual tooth loss if untreated.

Periodontitis represents one of the leading causes of adult tooth loss worldwide.

Etiology

Periodontitis develops mainly due to:

• Persistent dental plaque accumulation

• Subgingival bacterial infection

• Poor oral hygiene

• Untreated gingivitis

• Calculus deposition

• Smoking

• Systemic diseases (especially diabetes mellitus)

• Genetic susceptibility

• Immunosuppression

• Hormonal changes

Risk Factors

• Poor oral hygiene practices

• Tobacco smoking

• Diabetes mellitus

• HIV/AIDS

• Malnutrition

• Increasing age

• Pregnancy

• Stress

• Obesity

• Certain medications causing gingival enlargement

• Irregular dental attendance

Pathophysiology

Disease progression occurs through the following mechanism:

1. Accumulation of dental plaque along gingival margin.

2. Bacterial toxins trigger chronic inflammatory response.

3. Destruction of gingival connective tissue occurs.

4. Apical migration of junctional epithelium develops.

5. Periodontal pocket formation occurs.

6. Breakdown of periodontal ligament fibers.

7. Progressive alveolar bone resorption.

8. Increased tooth mobility and eventual tooth loss.

Common periodontal pathogens include:

• Porphyromonas gingivalis

• Aggregatibacter actinomycetemcomitans

• Prevotella intermedia

• Fusobacterium nucleatum

Signs and Symptoms

• Reddened and swollen gingiva

• Bleeding gums during brushing or probing

• Periodontal pocket formation

• Gingival recession

• Persistent bad breath (halitosis)

• Tooth mobility

• Gum tenderness

• Pus discharge from periodontal pockets

• Spacing between teeth in advanced disease

• Difficulty chewing

Diagnostic Criteria

Diagnosis is clinical and supported by radiological findings:

• Inflamed gingiva with bleeding on probing

• Presence of periodontal pockets (>4 mm)

• Clinical attachment loss

• Gingival recession

• Tooth mobility

• Radiological evidence of alveolar bone loss

Investigations

• Periodontal probing depth measurement

• Orthopantomogram (OPG) to determine extent of bone loss

• Periapical dental radiographs

• Plaque and bleeding indices

• Blood glucose testing in suspected diabetes

• Microbiological testing in refractory disease (when available)

Management

Treatment Principles

Management aims to:

• Eliminate infection

• Reduce periodontal inflammation

• Halt disease progression

• Preserve supporting structures

• Prevent tooth loss

Non-Pharmacological Management

• Patient education on proper oral hygiene practices

• Professional plaque and calculus removal

• Scaling and root planing (may require multiple visits)

• Subgingival debridement

• Occlusal adjustment when necessary

• Smoking cessation counseling

• Regular periodontal maintenance therapy

• Surgical periodontal therapy in advanced disease

• Referral to periodontal specialist for resistant or systemic cases

Pharmacological Management

Antiseptic Mouth Care

(Do not swallow)

• Hydrogen peroxide 3% mouthwash every 6 hours for at least 5 days

OR

• Chlorhexidine gluconate 0.2% mouthwash every 12 hours for at least 5–14 days

Antibiotic Therapy

Antibiotics are indicated only in severe, aggressive, refractory periodontitis or periodontal abscess.

• Metronidazole 400 mg orally every 8 hours for 8 days

AND EITHER

• Amoxicillin 500 mg orally every 8 hours for 8 days

OR

• Doxycycline 100 mg orally every 12 hours for 10 days

(According to Tanzania Standard Treatment Guidelines 2022)

Complications

Untreated periodontitis may result in:

• Progressive alveolar bone loss

• Periodontal abscess formation

• Tooth mobility

• Tooth migration

• Tooth loss

• Chronic halitosis

• Orofacial infection spread

• Increased risk of systemic inflammatory diseases

Prevention

• Brush teeth twice daily using fluoridated toothpaste

• Daily dental floss use

• Regular professional dental cleaning

• Early treatment of gingivitis

• Smoking cessation

• Glycemic control in diabetic patients

• Balanced nutrition

• Routine dental examination every 6 months

Patient Education

• Bleeding gums indicate disease and require treatment

• Periodontitis is preventable but irreversible once advanced

• Proper oral hygiene slows disease progression

• Regular dental visits are essential

• Control of systemic diseases improves outcomes

Prognosis

Prognosis depends on disease severity, oral hygiene compliance, and systemic health status. Early intervention stabilizes disease progression, whereas advanced untreated disease commonly results in tooth loss.