Management of necrotising gingivitis

Thorough debridement of plaque and necrotic debris is necessary for successful management of necrotising gingivitis. However, it may not be possible to complete debridement at the initial presentation because necrotising gingivitis can be associated with significant pain.

Begin management of necrotising gingivitis with:

  • gentle removal of as much plaque and necrotic debris as possible, using local anaesthetics if necessary
  • local irrigation with chlorhexidine 0.2% mouthwash or hydrogen peroxide 3% solution. Chlorhexidine mouthwash or hydrogen peroxide solution (as below) may also be used if pain limits the patient’s ability to mechanically clean their teeth
  • antibiotic therapy (as below)
  • analgesics (see Choice of analgesic for acute dental pain)
  • advice to stop smoking.

Profoundly immunocompromised patients or patients with severe cases of necrotising gingivitis require prompt referral for specialist management in addition to the management above.

For antibiotic therapy of necrotising gingivitis, use:

metronidazole 400 mg orally, 12-hourly for 3 to 5 days. gingivitis, necrotising metronidazole    

If pain and inflammation restrict oral hygiene practices, recommend short-term use of a mouthwash to reduce plaque formation; use:

1 hydrogen peroxide 3% solution 5 mL, mixed with 5 mL of warm water, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced gingivitis, necrotising hydrogen peroxide    

OR

1 hydrogen peroxide 1.5% solution 10 mL, rinsed in the mouth for 1 minute then spat out, 12-hourly until pain has reduced hydrogen peroxide    

OR

2 chlorhexidine 0.2% mouthwash 10 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced1 gingivitis, necrotising chlorhexidine    

OR

2 chlorhexidine 0.12% mouthwash 15 mL rinsed in the mouth for 1 minute then spat out, 8- to 12-hourly until pain has reduced1 . chlorhexidine    

Review the patient in 48 to 72 hours; perform a periodontal examination and provide the patient with advice on oral hygiene. Perform thorough debridement as soon as possible to prevent recurrence.

A poor response to treatment or recurrence of symptoms is usually due to inadequate debridement or a lack of improvement in oral hygiene, rather than an ineffective antibiotic regimen. If the infection has not responded to appropriate management (complete debridement, antibiotic therapy, improved oral hygiene) within 2 weeks, refer for specialist management.

Note: Treatment failure is usually due to inadequate debridement or poor oral hygiene, rather than ineffective antibiotic therapy.
1 When used for more than a few days, chlorhexidine may cause a superficial discolouration of the teeth and fillings (see Chlorhexidine for more information).Return