Periodontitis - clinical fact sheet and MCQ

Overview 

Periodontitis is a chronic inflammatory disease of the supporting structures of teeth, including the gingiva, periodontal ligament and alveolar bone. It is often silent yet causes a progressive destruction of the structures that hold the tooth in the bone. This results in periodontal pocket formation, gingival recession, tooth mobility, and eventual tooth loss. The condition affects approximately 50% of the population and typically progresses slowly, however, acute episodes may necessitate urgent treatment by a dentist.

GPs play an important role in the early identification and management of risk factors for periodontitis, such as age, smoking, diabetes, obesity, and obstructive sleep apnoea. 

Tooth structure and dental plaque formation

(image credit: https://upload.wikimedia.org/wikipedia/commons/0/01/Depiction_of_a_Periodontitis_patient.png)

A tooth consists of:

• enamel (outermost)

• dentin, which lies beneath the enamel and provides support

• pulp, a soft tissue containing nerves and blood vessels

• cementum, which covers the tooth root and helps anchor it to the surrounding bone

The periodontium, which supports and maintains the tooth in its socket, includes the gingiva (gums), periodontal ligament, alveolar bone, and cementum.

Dental plaque formation is a dynamic process:

• adhesion of salivary proteins to the tooth surface

• bacteria to attach and multiply to this coating, leading to the development of a structured biofilm

• the periodontium responds with an inflammatory reaction

• tissue destruction and compromise to the periodontal ligament occur

• inflammation progresses from the gingival margin into the alveolar bone

• periodontal pocket forms around a tooth, providing a reservoir of pathogenic bacteria and calculus (hardened, mineralised plaque)

Diagnosis of periodontitis

1. Presenting features:

• halitosis

• an unpleasant taste

• gingival bleeding

• drifting or loose teeth in advanced stages

• pain is not commonly reported until the disease is severe

• gingival inflammation and bleeding

• formation of periodontal pockets, ie attachment loss (history of tooth mobility and spacing between teeth, teeth looking taller)

• gingival recession and exposure of root surfaces

• hormonal (puberty, pregnancy) or metabolic (obesity) changes causing localised or generalised inflammation of gums

2. Major risk factors and comorbidities:

• smoking

• poorly controlled diabetes

• compromised immune response

• insufficient routine oral hygiene

The disease burden increases with age and is linked to systemic health outcomes, including cardiovascular disease, and diabetes. Some studies have shown a bidirectional relationship between periodontitis and glycemic control, suggesting managing periodontitis positively influences control of blood sugar control in type 2 diabetes. Studies have also suggested deteriorating gums can be a sign of undiagnosed type 2 diabetes. Furthermore, there is growing evidence suggesting a link between obstructive sleep apnoea (OSA) and increased risk of periodontitis. 

Current classification of periodontitis is based on:

• stage: clinical and/or radiographic amount of tissue and bone loss as a result of periodontitis. Outlines the complexity of the treatment needed and indicates severity. 

• grade: reflects rate of progression, anticipated response to therapy, and risk factors e.g. smoking, diabetes

Periodontitis staging and grading is outlined in detail here. This system enables risk stratification and tailored care planning. 

3. Differential diagnoses for periodontitis include:

• gingivitis (reversible inflammation without attachment loss)

• necrotising periodontal disease (distinctive acute form, often with systemic symptoms)

• endodontic–periodontal lesions (combined pulpal and periodontal origin)

• desquamative gingivitis (often due to mucocutaneous diseases such as lichen planus)

4. Red flags for urgent referral include:

• rapid attachment loss and bone destruction, particularly in younger individuals

• lack of correlation between plaque levels and disease severity

• systemic signs such as fever or malaise (suggesting systemic disease or necrotising disease)

• presentation in children (consider underlying systemic diseases such as leukaemia, type 1 diabetes, or cyclic neutropenia)

Children and adults with rapidly progressive disease require urgent collaborative care from periodontist and pediatric dentists.

Management of periodontitis

The cornerstone of periodontitis management is the control of bacterial biofilm and modification of contributing risk factors. GPs should encourage patients to seek regular dental care and support behavioural changes.

1. Management of periodontitis in primary practice

• Risk factor control: support for smoking cessation and diabetes optimisation

• Oral hygiene instruction: brushing technique, flossing, and interdental cleaning should be reviewed and reinforced

• recommend regular dentist visits for debridement, correction of plaque-retentive factors, and maintenance

• Mouthwashes do not penetrate periodontal pockets but antiseptic mouthwashes may be a useful adjunct for short-term use in patients with gingivitis 

• short-term use of 1.5% topical hydrogen peroxide may be used for antiseptic properties

• 0.12% or 0.2% chlorhexidine mouthwash may be used no longer than two weeks for bactericidal, fungicidal and antiviral effects

2. Refer patients for periodontal review if:

• periodontitis is severe (deep pockets, extensive attachment loss)

• there is no response to primary care interventions

• the disease is rapidly progressing or the patient is immunocompromised

Antibiotics are rarely indicated and should be reserved for specific scenarios with dentist or periodontist referral.

References

Therapeutic Guidelines. Periodontitis. 2019. (last accessed April 2025).

McColl, E. Periodontal tips for primary care. Br Dent J. 2022; 232: 72–73.

West N, Chapple I, et al. BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice. Journal of Dentistry. 2021;106:103562.

Stöhr, J., Barbaresko, J., Neuenschwander, M. et al. Bidirectional association between periodontal disease and diabetes mellitus: a systematic review and meta-analysis of cohort studies. Sci Rep.2021;11: 13686.

Kalhan AC, Wong ML, Allen F, Gao X. Periodontal disease and systemic health: An update for medical practitioners. Annals. 2022;51(9):567-574. 

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