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Referral and warning signs
When to refer
Refer to dental personnel (HC4+) for professional cleaning (scaling/polishing) and oral hygiene instruction. Refer if gingival enlargement present (medication-related?) or if periodontitis suspected.
Red flags
- Significant gum recession.
- Tooth mobility.
- Deep periodontal pockets (>4mm).
- Signs of acute infection (ANUG).
Signs and symptoms
- Redness and swelling of the gingival margins.
- Bleeding gums (especially during brushing, flossing, or gentle probing).
- Gums may be tender.
- Bad breath (halitosis).
- No loss of periodontal attachment (bone loss) - distinguishes from periodontitis.
- Visible plaque and calculus (tartar) deposits.
Risk factors
- Poor oral hygiene (inadequate brushing/flossing).
- Plaque accumulation.
- Hormonal changes (puberty, pregnancy, menstruation).
- Certain medications (e.g., phenytoin, calcium channel blockers, cyclosporine - can cause gingival enlargement).
- Systemic diseases (e.g., uncontrolled diabetes).
- Smoking.
- Malnutrition (esp. Vitamin C deficiency - rare).
Diagnosis
Clinical assessment
Based on clinical examination showing signs of inflammation (redness, swelling, bleeding on probing) localized to the gingiva, with presence of plaque/calculus, and NO evidence of attachment loss (no deep pockets).
Investigations
- Dental examination.
- Periodontal probing (pocket depths generally <3-4mm, no attachment loss).
Diagnostic criteria
Clinical signs of gingival inflammation (redness, swelling, bleeding) without loss of periodontal attachment.
Management
Non-pharmacological management
- Improved Oral Hygiene (Mainstay):
- - Thorough tooth brushing twice daily with fluoride toothpaste.
- - Daily interdental cleaning (flossing or interdental brushes).
- Professional Dental Cleaning:
- - Scaling and polishing to remove plaque and calculus deposits (tartar). (LOC: HC4+)
Pharmacological treatment
- Antiseptic Mouthwashes: (Adjunct to mechanical cleaning, not replacement)
- - Chlorhexidine gluconate 0.12% or 0.2% mouthwash BID for short periods (1-2 weeks) can reduce plaque/gingivitis. (LOC: HC2+)
- - Warm salt water rinses (1/2 tsp salt in glass warm water) TID. (LOC: HC2)
- - Hydrogen peroxide 3% diluted 1:1 with water (or 6% diluted 1:4) rinse TID (short term). (LOC: HC2)
- Systemic Antibiotics: NOT indicated for chronic gingivitis unless associated with systemic signs (rare) or specific aggressive forms (ANUG - see ODH014).
Monitoring
Re-evaluate oral hygiene practices and gingival health at follow-up dental visits.
Complications
- If untreated, can progress to periodontitis (attachment loss, bone loss, tooth loss).
- Persistent bleeding, discomfort, halitosis.
Prevention
- Meticulous daily oral hygiene (brushing, flossing).
- Regular professional dental cleanings.
- Control systemic risk factors (diabetes, smoking).
Patient education
- Explanation of gingivitis as reversible gum inflammation caused by plaque.
- Demonstration of proper brushing and flossing techniques.
- Importance of regular professional cleanings.
- Role of mouthwashes as adjuncts.
- Connection between oral health and systemic health (e.g., diabetes).
Uganda-specific notes
Very common due to varying levels of oral hygiene practice. Focus on patient education for brushing/flossing and referral for scaling.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.2.5, 23.2.5.1