Gingivitis vs Periodontitis: Diagnosis and Treatment
Key Distinguishing Features
Gingivitis is reversible gingival inflammation without attachment loss or bone destruction, while periodontitis involves irreversible destruction of periodontal ligament and alveolar bone. 1
Clinical Differentiation
Gingivitis:
- Gingival inflammation (redness, swelling) with bleeding on probing 2, 3
- No clinical attachment loss or radiographic bone loss 1
- Reversible with proper treatment 1
- May occur on intact or reduced periodontium 1
Periodontitis:
- Periodontal pocket formation (deepening of gingival sulcus) 4
- Clinical attachment loss and radiographic alveolar bone loss 4, 5
- Reduced cementum thickness affecting ligament fiber attachment 4
- Absent lamina dura on radiographs 4
- Horizontal bone loss pattern 4
- May progress to abscess formation with pain 4
- Irreversible tissue destruction 1
Diagnostic Workup
All patients require: 5
- Full periodontal examination with probing depths and bleeding on probing at all sites 5
- Plaque assessment, furcation involvement, recession, and tooth mobility evaluation 5
- Full-mouth radiographs to assess bone levels in suspected periodontitis 5
- Risk factor assessment: smoking status, diabetes screening 5, 6
Treatment Algorithm for Gingivitis
Primary Treatment (First-Line)
Professional mechanical plaque removal (scaling) combined with patient education on proper oral hygiene is the cornerstone of gingivitis treatment. 2
Step 1: Professional Intervention 2
- Scaling and supragingival debridement 2
- Patient education on proper brushing technique (Bass or modified Bass method) 2
- Soft toothbrush replacement monthly 2
- Fluoride-containing, non-foaming toothpaste 2
Step 2: Adjunctive Chemical Plaque Control 2, 3
- 0.12-0.2% chlorhexidine mouthwash: 15mL twice daily for 60 seconds 2, 3
- Critical timing: Wait 30 minutes after toothbrushing before rinsing to avoid inactivation by toothpaste ingredients 2
- Duration: Typically 2-4 weeks 2
- Side effects: Tooth staining, taste alteration, increased calculus formation 2
Step 3: Reassessment 2
Alternative Natural Product-Based Mouthwashes
For patients who cannot tolerate chlorhexidine or prefer natural alternatives, several options show comparable efficacy: 2
- Triphala mouthwash: 10mL twice daily—cost-effective with no reported side effects 7, 2
- Aloe vera mouthwash (100%): Twice daily for 1 minute 7, 2
- 0.1% turmeric/curcumin mouthwash: 10mL twice daily for 21 days 2
- 0.25% lemongrass oil or green tea mouthwash: Comparable anti-plaque effects without tooth staining 2
When to Consider Antibiotics
Antibiotics are NOT recommended for routine gingivitis. 2 Consider only if: 2, 8
- Fever, malaise, or lymphadenopathy present (systemic involvement) 2, 8
- Infection extends into facial spaces 2
- First choice: Amoxicillin 2
- Second choice: Amoxicillin-clavulanic acid 2
Critical pitfall: Never prescribe antibiotics for undefined febrile illness without obtaining blood cultures first, as this can mask infective endocarditis 8
Treatment Algorithm for Periodontitis
Primary Treatment (First-Line)
Periodontitis requires more aggressive mechanical debridement than gingivitis, including subgingival scaling and root planing. 7
Step 1: Nonsurgical Periodontal Therapy 7, 6
- Subgingival scaling and root planing 7
- Supragingival debridement 7
- Patient education on oral hygiene 6
- Risk factor modification: smoking cessation, diabetes control 5, 6
Step 2: Supportive Periodontal Maintenance 7
- Frequency: Twice-yearly visits minimum 7
- Periodontal risk reassessment at each visit 7
- Repeat subgingival debridement as needed 7
- Regular monitoring to prevent recurrence 7
Step 3: Adjunctive Antimicrobial Therapy 7
- Same chlorhexidine or natural product mouthwash protocols as gingivitis 2
- Proper periodontal maintenance is essential to prevent peri-implant disease in patients with dental implants 7
Surgical Intervention
Consider surgical therapy when: 7, 6
- Nonsurgical therapy fails to resolve deep pockets 6
- Persistent inflammation despite adequate home care 6
- Furcation involvement or severe bone loss 6
Special Considerations for High-Risk Patients
Smoking and Diabetes
Both smoking and diabetes are confirmed risk factors that worsen periodontitis severity and treatment outcomes. 4, 6
- Aggressive risk factor management is mandatory 5, 6
- Smoking cessation counseling at every visit 6
- Diabetes screening and optimization 5, 6
Medication-Induced Gingival Hyperplasia
Calcium channel blockers and cyclosporine commonly cause gingival enlargement that complicates periodontal disease. 7, 8
- Consult with prescribing physician to consider medication substitution 7
- Switch cyclosporine to tacrolimus if possible (less gingival hyperplasia) 7, 8
- Maintain meticulous periodontal control 7
Patients with Systemic Disease or Immunosuppression
Dialysis patients, transplant recipients, and immunocompromised patients require more frequent monitoring. 7
- Increased susceptibility to periodontal infections 7
- Higher risk of peri-implantitis if dental implants present 7
- More aggressive maintenance protocols 7
Critical Pitfalls to Avoid
Never initiate antibiotics without proper indication: Routine gingivitis and periodontitis do not require systemic antibiotics 2. Inappropriate antibiotic use can mask serious infections like infective endocarditis 8.
Never skip the 30-minute wait between brushing and chlorhexidine rinsing: Toothpaste ingredients inactivate chlorhexidine, rendering it ineffective 2.
Never assume treated periodontitis patients are "cured": Successfully treated periodontitis patients remain at increased risk for recurrence and require lifelong supportive periodontal therapy 1.
Never overlook systemic risk factors: Poor diabetes control and continued smoking dramatically worsen periodontal outcomes 4, 6.
Never prescribe antibiotics without surgical intervention for dental abscesses: Antibiotics alone without source control lead to treatment failure 8.