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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Gingivitis/periodontitis

Spyridon Marinopoulos, M.D.
04-24-2009

  • Information below applies to Zambia, though some treatment modalities may not be available.
Zambia Information Author: Spyridon Marinopoulos, M.D.

PATHOGENS

  • Gemella morbillorum 
  • Dialister spp. 
  • Veillonella spp. 
  • Peptostreptococcus micros
  • Candida albicans   (more common in HIV with high VL)
  • Porphyromonas gingivalis 
  • Prevotella intermedia     
  • Tannerella forsythia     
  • Actinobacillus actinomycetemcomitans
  • Treponema denticola      
  • Bacteroides forsythus
  • Capnocytophaga spp.
  • Spirochetes
  • Gram negative anaerobes
  • Eikenella corrodens

CLINICAL

  • Gingivitis: Gum bleeding (spontaneous or with minor injury) w/ associated edema/erythema.
  • Linear gingival erythema (HIV gingivitis): brightly inflamed, erythematous band of marginal and papillary gingiva. Disproportional to amount of visible plaque. +/- bleeding. Pain not prominent. Not assoc w/ CD4. Does not resolve despite periodontal debridement.
  • Necrotizing ulcerative gingivitis (NUG) or HIV-NUG ("trench mouth"): fetid breath, blunting of interdental papillae & ulcerative necrotic gingival sloughing with bleeding +/- fever/regional LN. Rapid progression. Can evolve into necrotizing ulcerative periodonditis w/destruction of periodontium and bone involvement.
  • Periodontitis: inflamed gingiva w/ loss of supportive connective tissues. Typically no Sx. PE: bone craters w/increased gingival pocket (probing) depth & tooth mobility. X-ray may show bone loss.
  • Necrotizing ulcerative periodontitis (NUP) or HIV-NUP: Severely painful gingival tissue, severe loss of periodontal attachment & alveolar bone destruction w/ eventual necrosis. Rapid progression. Bleeding spontaneous or w/ minor probing. Progresses from NUG. CD4 usually <200. Dx: KS, NHL, CMV
  • Periodontal abscess: acute, tender, purulent inflammation in gingival wall of periodontal pocket + fluctuance +/- sinus tract +/- regional LN +/- tender/sensitive adjacent teeth + fever if severe
  • Factors predisposing to poor gingival and periodontal health include HIV, pregnancy (hormonal shifts), smoking, diabetes, leukemia, Down syndrome, other immune/leukocyte disorders (Job's syndrome, leukocyte adhesion deficiencies, Chediak-Higashi syndrome, Papillon-Lefevre syndrome, chronic granulomatous disease), exogenous immunosuppression (chemotherapy), head and neck radiation, medications causing gingival hyperplasia (nifedipine and other calcium channel blockers, dilantin, cyclosporin) or xerostomia etc.

DIAGNOSIS

  • Visual inspection sufficient in most cases
  • X-rays may reveal bone loss
  • Consider Cx/Bx in persistent/resistant cases

TREATMENT

TOPICAL THERAPY

  • Gingivitis/periodontitis: Plaque removal w/ scaling & root planing (SRP) q3mos effective in most cases w/o need for abx. Prevention: meticulous hygiene w/brushing, flossing & regular dental visits
  • Initiate scaling and root planing (SRP)+ home hygiene. Consider antibacterial mouthwash (see below) if pts unwilling/unable to comply w/home hygiene measures. Assess for response 1-3 mos post Rx
  • Exceptions to above: fulminant disease or disease caused by A. actinomycetemcomitans (Aa), including juvenile & some adult: not responsive to SRP alone & requires post-SRP adjunctive systemic ABx
  • Chlorhexidine (PerioGard) 0.12% oral rinse 15 cc twice daily between dental visits reduces bacterial flora/prevents plaque advancement. May cause tooth staining & promote bacterial resistance w/ prolonged use
  • Advise smoking cessation
  • Linear gingival erythema: Plaque removal w/ SRP q3mos + chlorhexidine 0.12% oral rinse 15 cc twice daily indefinitely prevents progression to NUP
  • Refractory and/or recurrent periodontitis: Recommend Cx prior to Rx. Limited disease: SRP + local-delivery ABx. Extensive disease: SRP + systemic ABx (see below)
  • Local delivery adjunct to SRP (applied once): Minocycline 1 mg microsphere (Arestin), tetracycline 12.7 mg fiber (Actisite), doxycycline 10% gel (Atridox), chlorhexidine 2.5 mg chip (PerioChip)
  • Other Rx: (Submicrobial dose) doxycycline hyclate (Periostat) 20 mg PO twice daily x 90 d (up to 9 mos) reduces periodontitis by inhibiting collagenase. Effect small but significant. Useful as adjunct to SRP
  • Periodontal abscess: NSAIDs +/- weak narcotic opioids for pain control. I&D is primary treatment w/ABx supportive if systemic Sx (fever, LN etc). Refer to dentist within 24 hrs
SYSTEMIC ANTIBIOTICS

  • Although SRP alone effective in most pts w/ periodontal disease, strong evidence exists for use of ABx as adjunct to SRP in severe/refractory/aggressive cases
  • Refractory and/or recurrent periodontitis: Recommend Cx prior to Rx. If sites of disease few, SRP + local-delivery ABx (see above). If extensive disease, SRP + systemic ABx (below).
  • If Cx unavailable & no prior ABx: tetracycline 250 mg PO q6h OR doxycline/minocycline 200 mg PO x 1 then 100 mg PO once-daily x 14 d. Alt:amoxicillin/clavulanate 250-500 mg PO q8h x 10 d. PCN ALLERGY: clindamycin 150-300 mg PO q6h x 7-10 d
  • More aggressive disease: amoxicillin 375 mg + metronidazole 250 mg PO q8h x 7d. PCN ALLERGY: clindamycin 150-300 mg PO q6h x 10d very effective. Alternative: metronidazole 500mg + ciprofloxacin 500 mg PO twice-daily x 7d
  • Linear gingival erythema: Test for Candida and treat if positive; eradication of intraoral Candida often results in disappearance of characteristic lesions
  • ANUG (trench mouth), NUP, HIV-NUG, HIV-NUP: metronidazole 250 mg + amoxicillin/clavulanate 250 mg PO q8h x 7 d (add nystatin rinses 5 mL 4x/d or clotrimazole troches 10 mg 5x/d or fluconazole 200 mg PO once-daily x 7-14 d given Candida overgrowth w/ ABx use). PCN allergy: metronidazole 500 mg PO + ciprofloxacin 500 mg PO q12h x 7 d (with antifungal therapy noted above)
  • Periodontal abscess: ABx controversial. Use if severe/systemic Sx, always in conjunction w/ I&D. Cover anaerobes. 7 day course typical, but can also treat for 3 days then reassess.  Amoxicillin/clavulanate 500 mg PO q8h. PCN allergy: metronidazole 500 mg PO q8h. Rx failure: when possible, obtain Cx and tailor ABx accordingly. Empiric Rx for Rx failure: clindamycin 300 mg PO q6h

Drug Comments

DrugRecommendations/Comments
 Amoxicillin + ClavulanateGood for Rx of aggressive periodontitis when beta-lactamase resistance a concern. Good alternative to clindamycin. Used in combination with metronidazole to treat necrotizing ulcerative periodontitis in HIV. Three times a day better than twice-daily dosing.
Ciprofloxacin Used in combination with metronidazole in PCN allergic patients to treat refractory and/or aggressive disease. Excellent coverage of enteric gram negatives.
Clindamycin Excellent alternative to metronidazole for anaerobic coverage with excellent penetration into alveolar bone. Very effective adjunctive rx for refractory periodontitis. Risk of C. difficile colitis
Doxycycline Alternative to tetracycline with better absorption and more convenient dosing.
Metronidazole Great choice for mouth anaerobes. May arrest disease progression in refractory periodontitis patients with Porphyromonas gingivalis and/or Prevotella intermedia. Used in combination with amoxicillin , amoxicillin/clavulanate, or ciprofloxacin to Rx aggressive or necrotizing forms of periodontal disease. Avoid alcohol (disulfiram potential). P450 metabolism.
Nystatin Use in combination with PO ABx in HIV patients to suppress/treat Candida.
Penicillin Although preferred for dental infections, not agent of choice for periodontal disease as it does not cover mouth anaerobes and there is significant resistance.
Tetracycline Excellent accumulation into crevicular fluid, better than any other ABx class. Good agent for periodontal disease caused by A. actinomycetemcomitans, but there is emerging resistance. GI side effects. May stain teeth. Photosensitivity. Food restrictions and four times a day dosing inconvenient.

FOLLOW UP

  • Gingivitis/periodontitis: q3mos indefinitely for plaque removal w/ SRP
  • Linear gingival erythema: q3mos and use chlorhexidine mouth rinse twice-daily indefinitely
  • NUP: Return in 24 h for observation and additional debridement of necrotic tissues, in 7 d for meticulous SRP, q3mos indefinitely.

OTHER INFORMATION

  • Recommendations are author's opinion. Adult gingivitis & periodontitis preventable with meticulous oral hygiene & regular dental visits. Rx consists of SRP +/- adjunctive ABx.
  • HIV+ patients can present with atypical, fulminant disease & require indefinite close follow up. Unique bacterial flora includes GNRs, enterics and fungi. Must cover Candida.
  • Use ABx adjunctively in fulminant/aggressive/recurrent disease. Prefer topical if few teeth involved, but systemic justified in more diffuse/severe disease. Cx may aid in appropriate ABx selection.
  • Potential complications include tooth loss, necrotizing stomatitis (noma), sinusitis, cavernous sinus thrombosis, Ludwig's angina, retro/parapharyngeal abscess, osteomyelitis, endocarditis, brain abscess.
  • In all patients, including HIV+, gingivitis/periodontitis may represent initial presentation of systemic illness: DM, leukemia, other immune. Also consider meds causing gingival hyperplasia: dilantin, nifedipine, cyclosporin etc.

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