Periodontitis
Background
- Chronic inflammatory condition of the supporting tissues of teeth caused by bacterial biofilm
- Results in progressive destruction of periodontal ligament and alveolar bone
- Major cause of tooth loss in adults
- EM relevance: Patients present with dental pain, gingival bleeding, or loose teeth; must differentiate from dental abscess and ANUG (acute emergencies)
Clinical Features
- Gingival bleeding, erythema, swelling
- Deep periodontal pockets (>3mm)
- Gingival recession, exposed root surfaces
- Tooth mobility
- Halitosis
- Usually chronic and painless (pain suggests abscess complication)
Differential Diagnosis
- Gingivitis — reversible gingival inflammation without bone loss
- Dental abscess — localized fluctuant swelling, severe pain, possible systemic toxicity
- ANUG (acute necrotizing ulcerative gingivitis) — acute onset, necrotic interdental papillae, fetid breath, pain, fever
- Leukemia or other hematologic malignancy — gingival hyperplasia with bleeding
Evaluation
- Clinical exam: assess for fluctuance, facial swelling, trismus, floor of mouth elevation (Ludwig's angina)
- In the ED: Rule out abscess and deep space infection
- Dental radiographs showing alveolar bone loss (definitive, usually outpatient)
Management
- In the ED: Pain control, rule out abscess
- Chlorhexidine 0.12% oral rinse BID
- Antibiotics as adjunct for severe disease:
- Doxycycline 100mg PO daily (as adjunct to scaling and root planing)
- Definitive treatment is scaling and root planing (dental office)
Disposition
- Outpatient dental/periodontal referral
- Red flags requiring urgent evaluation: Facial swelling, trismus, dysphagia, floor of mouth elevation, fever